Petition For Review Of Arbitration Decision - Illinois Workers' Compensation Commission Page 2
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1
2P
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 _____ mailed with proper postage _____
in the city of _________________________________ a copy of this form
at
AM
on
to each party at the address(es) listed below.
___________
__________________
____________________________________________
Signature of person completing Proof of Service
Signed and sworn to before me on __________________
___________________________________________
Notary Public
IC11 page 2
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