Petition For Review Of Arbitration Decision - Illinois Workers' Compensation Commission
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1
2ILLINOIS WORKERS’ COMPENSATION COMMISSION
PETITION FOR REVIEW OF ARBITRATION DECISION
To appeal an arbitration decision, file two copies of this form within 30 days of receipt of the decision.
______________________________________
Case #
WC
________
_______________
Employee/Petitioner
v.
______________________________________
Employer/Respondent
The petitioner ____ respondent ____ requests the Commission to review the arbitration decision for this case,
filed on _______________ and received on _______________ , and to take the following steps:
1. Furnish a transcript of the arbitration hearings, including all exhibits, to be presented to the Commission.
I guarantee to pay for the cost to prepare the transcript within 30 days from the court reporter's written request, even if I later
withdraw this appeal, and enter myself as surety therefor. Note: The first party to file a petition will be charged for the cost
to prepare the transcript (original rate).
Provide ____ copy/copies of the transcript. I similarly guarantee payment at the copy rate.
2. Extend the time allowed to file the transcript or the agreed statement of facts by 30 days past the time allowed by statute
or stipulation.
3. Consider the issues checked below to which I take exception:
A
M
________________
CCIDENT
EDICAL EXPENSES
O
(explain)
THER
___
___
Did it occur?
Is there a causal connection?
P
ENALTIES AND FEES
___
___
Did it arise out of employment?
Is the charge reasonable?
___
Section 16
___
___
Was it in the course of
Was the treatment reasonably
___
Section 19(k)
employment?
necessary?
___
Section 19(l)
___
___
Is the date correct?
Is prospective medical care
necessary?
P
ERMANENT DISABILITY
B
R
ENEFIT
ATES
N
OTICE
___
Is there a causal connection?
___
Are the benefit rates correct?
___
Was the respondent given proper
___
What is the nature and extent of the
___
Are the wage calculations
notice?
disability?
correct?
O
CCUPATIONAL DISEASE
S
TATUTE OF LIMITATIONS
E
MPLOYMENT
___
Was there an exposure?
___
Was the case filed within the statute
___
Was there an employer-employee
of limitations?
___
relationship?
Was there a disease?
___
Did it arise out of employment?
T
EMPORARY DISABILITY
J
URISDICTION
___
Was it in the course of
___
Is there a causal connection?
___
Does the Commission have
employment?
jurisdiction?
___
Is the duration of the disability
___
What was the last date of exposure?
correct?
4. Oral argument: Requested ___ Waived ___
_________________________________________________
______________________________________________
Signature
Telephone number
Street address
_________________________________________________
______________________________________________
Name (please print; attorneys, please include IC attorney code #)
City, State, Zip code
IC11 12/04 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611
Toll-free line 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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