Illinois Workers' Compensation Form
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1ILLINOIS WORKERS’ COMPENSATION COMMISSION
STIPULATION TO SUBSTITUTE ATTORNEYS
A
,
: please attach a copy of the Attorney Representation Agreement.
TTENTION
PETITIONER
Case #
WC
_____________________________________________
______
__________________
Employee/Petitioner
v.
_____________________________________________
Employer/Respondent
I, __________________________________ , want the attorney, _________________________________ ,
to appear on my behalf in this case.
__________________________________________
Signature of petitioner or respondent
I hereby withdraw as the attorney for the above party.
__________________________________________
Signature of attorney
__________________________________________
Name of attorney and IC attorney code # (please print)
__________________________________________
Name of law firm
I hereby enter my appearance as the attorney for the above party.
__________________________________________
Signature of attorney
__________________________________________
Name of attorney and IC attorney code # (please print)
__________________________________________
Street address
__________________________________________
City, State, Zip code
__________________ ______________________
Telephone number
Email address
_________________________________________
Date
IC29 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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