Illinois Workers Compensation Forms
Download a blank fillable Illinois Workers Compensation Forms in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Illinois Workers Compensation Forms with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1ILLINOIS WORKERS’ COMPENSATION COMMISSION
INJURED WORKERS’ BENEFIT FUND:
REQUEST FOR BENEFITS AND AFFIDAVIT
_________________________________
Case # ____ WC ___________
Employee/Petitioner
v.
_________________________________
Employer/Respondent
I, _____________________________________________________ , duly swear:
Petitioner’s name
The Injured Workers’ Benefit Fund was joined with the employer as a respondent in this case.
On _______________ , the Commission awarded $ ____________________ in benefits (excluding penalties
and attorneys’ fees). A copy of that document is attached.
The employer/respondent failed to obtain workers’ compensation insurance coverage for this case.
I now ask the Commission to pay the benefits due from the Injured Workers’ Benefit Fund.
Benefits paid to date by employer $ ____________________
Unpaid benefits $ ____________________
I understand that by accepting this compensation from the Illinois Workers’ Benefit Fund, I will not receive any
further monetary award from the Illinois Workers’ Benefit Fund for this case.
_______________________________________________________
________________________
Petitioner’s signature
Date
_______________________________________________________
________________________
Petitioner’s mailing address
Social Security Number (required)
Subscribed and sworn to before me
on ___________________________
_________________________________
Notary Public
IC44 6/08 100 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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal