Arbitration Case Information Sheet
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1ILLINOIS WORKERS’ COMPENSATION COMMISSION
ARBITRATION CASE INFORMATION SHEET
A
. Please complete this form, have both parties sign it, and place it in the arbitrator's message box next to the hearing room door or other
TTENTION
area designated by the arbitrator. Do not interrupt the hearings. Be as specific as possible.
You must see the arbitrator if your case is above the red line.
Arbitrator
_____________________________________________
________________________________
Employee/Petitioner
Case #
WC
________
________________________
v.
Today’s date
________________________________
_____________________________________________
Status call date and line #
______________________
Employer/Respondent
Please check the appropriate box.
❑
Petitioner is receiving TTD.
❑
Petitioner is still treating. Name of doctor/clinic:
______________________________________________________
Date and nature of last treatment:
_____________________________________________________________________
❑
Petitioner is receiving vocational rehabilitation/job placement services.
Date and nature of last service:
________________________________________________________________________
❑
Deposition scheduled for
We expect to be ready for trial by
_____________________
_____________________
❑
Tentative settlement reached. We will submit contract for approval by
____________________________
❑
Request for approval of Medicare set-aside was submitted on
____________________________
❑
The case will be ready for trial by
____________________________
❑
The case was partially tried on
Next trial date is
__________________________
__________________________
❑
Other (explain)
______________________________________________________________________________________
_______________________________________________
___________________________________________
Signature of petitioner's attorney
Signature of respondent's attorney
_______________________________________________
___________________________________________
Name of petitioner's attorney (please print)
Name of respondent's attorney (please print)
_______________________________________________
___________________________________________
Email address
Email address
One-sided or ex parte communication is prohibited. Any correspondence sent to the Commission related to a pending matter must be sent
to all parties at the time it is sent to the Commission, and must list the parties to whom copies have been sent.
IC41 8/12 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611
Toll-free 866/352-3033
Web site:
Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084
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