Illinois Workers' Compensation Commission Notice Of Change Of Address
Download a blank fillable Illinois Workers' Compensation Commission Notice Of Change Of Address 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 Commission Notice Of Change Of Address 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
NOTICE OF CHANGE OF ADDRESS
A
. Please submit one form for each case.
TTENTION
_________________________________________
Case #
WC
______
__________________
Employee/Petitioner
v.
_________________________________________
Effective date _______________________
Employer/Respondent
Please change your records and direct any future correspondence regarding this case to:
_____________________________________
_________________________________
Signature of attorney
Street address
_____________________________________
_________________________________
Attorney’s name and attorney code # (please print)
City, State, Zip code
_____________________________________
_________________________________
Firm name
Telephone number
E-mail address
P
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
AM
at
on
_ to the respondent listed on this application and to each
___________
________________
additional party, if any, at the address listed below.
____________________________________________
Signature of person completing Proof of Service
Signed and sworn to before me on ________________
___________________________________________
Notary Public
IC26 9/08 100 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
Illinois Workers' Compensation Commission Petition For An Immediate Hearing Under Section 19(b) Of The Act Form
Legal
Illinois Workers' Compensation Commission Parent Guaranty Agreement In Connection With Self-insurance Privilege Form
Legal
Related Categories
Parent category: Legal