Illinois Workers' Compensation Form Page 2
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2Explain each item of disagreement (include legal and factual issues):
_______________________________________________
___________________________________________________
Signature of person completing form
Date
Street address
_______________________________________________
___________________________________________________
Name (please print; attorneys, please include IC attorney code #)
City, State, Zip code
P
S
ROOF OF
ERVICE
If the person who signed the Proof of Service is not an attorney, this form must be notarized.
I, ___________________________ , affirm that I delivered _____ sent by certified mail (return receipt requested) _____
a copy of this form
at
on
_ to each party at the address(es) listed below.
AM
___________
__________________
____________________________________________
Signature of person completing Proof of Service
Signed and sworn to before me on ___________________
______________________________________________
Notary Public
IC14b page 2
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