Fillable Petition For Review Under Section 19(H) Or 8(A) Of The Act Template printable pdf download

Petition For Review Under Section 19(H) Or 8(A) Of The Act Template

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ILLINOIS WORKERS’ COMPENSATION COMMISSION

PETITION FOR REVIEW UNDER

SECTION 19(h)

8(a) OF THE ACT

Please file two copies of this form.

Case #

_____________________________________________

______

__________________

Employee/Petitioner

_____________________________________________

Employer/Respondent

Today,

, the petitioner ___

respondent ___ petitions the Commission to review

______________

this case under Section 19(h)

___

Section 8(a)

___ of the Act.

I also ask the Commission to furnish

transcripts of the arbitration hearings, including all exhibits. I guarantee payment

______

for the cost to prepare and copy the transcripts, even if I later withdraw this petition, within 30 days from the court reporter's

written request, and enter myself as surety therefor.

_____________________________________________

Signature

Street address

_____________________________________________

Name (please print; attorneys, include IC code #)

City, State, Zip code

_____________________________________________

Telephone number

Transcript due date

ROOF OF

ERVICE

If the person who signed the Proof of Service is not an attorney, this form must be notarized.

, affirm that I delivered

mailed with proper postage

__________________________________________

______

in the city of

a copy of this form

________________________

to each party at the address(es) listed below.

______________

____________

_______________________________________

Signature of person completing Proof of Service

Signed and sworn to before me on ________________

_________________________________________

Notary Public

Section 19(h) of the Act provides that if the injured employee's disability has materially changed within 30 months after the decision or settlement contract (if

it provides for installment payments, rather than a lump sum payment), either party may request a review by the Commission.

Section 8(a) of the Act provides for a review by the Commission if additional medical expenses are incurred.

IC14 12/04 100 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