Dedimus Potestatem - Illinois Workers' Compensation Commission
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1
2STATE OF ILLINOIS
)
)
COUNTY OF __________________ )
ILLINOIS WORKERS' COMPENSATION COMMISSION
DEDIMUS POTESTATEM
__________________________________________
Case #
WC
________
____________________
Employee/Petitioner
v.
__________________________________________
Employer/Respondent
TO:
Because it has been represented to us that each of the individuals listed below:
(List each name and address)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
is a necessary witness in this case and cannot appear at the Commission hearing, we
appoint you to examine each witness under oath and to take his or her deposition in response to all
oral ____ written questions ____ posed by the petitioner or respondent at the following time
and place:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
and to certify each deposition to: Data Entry Unit, Illinois Workers' Compensation Commission,
100 W. Randolph St. #8-200, Chicago, IL 60601.
___________________________________________________
____________________________
Signature of arbitrator or commissioner
Date
IC33 12/04 100 W. Randolph St. #8-200 Chicago, IL 60601 312/814-611
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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