Application For Adjustment Of Claim (Application For Benefits)
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2ILLINOIS WORKERS’ COMPENSATION COMMISSION
APPLICATION FOR ADJUSTMENT OF CLAIM (APPLICATION FOR BENEFITS)
A
. Please type or print. Answer all questions. File three copies of this form.
TTENTION
Workers' Compensation Act ___ Occupational Diseases Act ___
Fatal case? No ___ Yes ___ Date of death __________
_________________________________
Case #
Employee/Petitioner
(Office use only)
v.
_________________________________
Location of accident ________________________
or last exposure
Employer/Respondent
City, State
______________________________________________________________________________________
1
Injured employee's name
Street address
City, State, Zip code
______________________________________________________________________________________
Employer's name
Street address
City, State, Zip code
Employee information: State Employee? Yes ____ No ____
Male ____ Female ____
Married ____ Single ____
# Dependents under age 18 ______
Birthdate _____________
Average weekly wage $ _________________
2
Date of accident
_______________________
The employer was notified of the accident orally ____ in writing ____
How did the accident occur? ____________________________________________________________________________
What part of the body was affected? ______________________________________________________________________
3
What is the nature of the injury? ___________________________________
Return-to-work date
________________
Is a Petition for an Immediate Hearing attached? Yes ____ No ____
Is the injured employee currently receiving temporary total disability benefits? Yes ____ No ____
If a prior application was ever filed for this employee, list the case number and its status ______________________________
A
,
. This is a legal document. Be sure all blanks are completed correctly and you understand the statements before
TTENTION
PETITIONER
4
you sign this. Refer to the Commission's Handbook on Workers' Compensation and Occupational Diseases
for more information.
_________________________________________
__________________________
Signature of petitioner
Date
A
P
'
A
PPEARANCE OF
ETITIONER
S
TTORNEY
Please attach a copy of the Attorney Representation Agreement.
_________________________________________
____________________________________________
Signature of attorney
Street address
_________________________________________
____________________________________________
5
Attorney’s name and IC code #
(please print)
City, State, Zip code
_________________________________________
___________________ _______________________
Firm name
Telephone number
E-mail address
IC1 5/12 100 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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