Illinois Workers Compensation Forms
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1ILLINOIS WORKERS’ COMPENSATION COMMISSION
MOTION TO VOLUNTARILY DISMISS
Case #
WC _______________
_____________________________________________
______
Employee/Petitioner
v.
_____________________________________________
Employer/Respondent
I petition the Commission to enter an order to dismiss
,
________________________________________
which is pending at arbitration ____ review ____ .
____________________________________________
____________________________________________
Signature of petitioner
Signature of attorney
____________________________________________
____________________________________________
Name of petitioner (please print)
Name of attorney (please print)
IC attorney code#
_______________
_______________
Date
Date
O
RDER
Pursuant to the above motion, the cause is hereby dismissed.
_______________
____________________________________________
Signature of arbitrator or commissioner
Date
IC17 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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Parent category: Legal