Illinois Workers' Compensation Form
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2ILLINOIS WORKERS’ COMPENSATION COMMISSION
RESPONSE TO PETITION FOR IMMEDIATE HEARING
UNDER SECTION 19(b-1) OF THE ACT
_________________________________
Case #
WC
______
_______________
Employee/Petitioner
v.
_________________________________
Employer/Respondent
On
, the respondent received the petitioner's Petition for an Immediate Hearing Under Section 19(b-1) of the
_______________
Act . By law, the respondent must reply within 15 days of receipt. The respondent makes the following claims:
Y
N
ES
O
The respondent was operating under the Act on the date of the alleged accident.
____
____
The petitioner was an employee of the respondent on the date of the alleged accident or exposure.
____
____
The alleged accident or disease arose out of and in the course of employment.
____
____
The respondent indicates its agreement or disagreement with the petitioner's allegations
regarding each of the following items:
A
D
GREE
ISAGREE
1.
Date, time, and location of the accident
____
____
2.
Description of the accident
____
____
3.
Nature of the injury
____
____
4.
Notice of the accident
____
____
5.
Employer's refusal to pay proper compensation and/or medical benefits, as claimed by petitioner
____
____
6.
Temporary Total Disability benefits
____
____
7.
The petitioner was treated by a medical provider selected by the employer.
____
____
8.
The respondent received a list of medical providers and dates of treatments.
____
____
9.
The parties tried but were unable to resolve this dispute.
____
____
10. The respondent received the names and addresses of employee's witnesses and others testifying.
____
____
11. The respondent received a recent medical report stating the employee is unable to work.
____
____
12. The respondent received authorization to review the employee's related medical records.
____
____
13. The respondent received documents supporting the employee's allegations.
____
____
14. The respondent received a list of documents demanded by the employee's subpoena.
____
____
A
,
. You must submit the following items with this response:
TTENTION
RESPONDENT
15. Complete copies of all documents in the employer's possession that you will use to support this response;
16. A list of all documents you are demanding by subpoena;
17. A list of the names and addresses of witnesses and others you will use to support this response;
18. A list of the name and address of each medical provider selected by the employer to examine the employee pursuant to
Section 12 of the Act, and the time and place of each exam.
IC14b 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
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