Please
mail accident reports to our Springfield office: 701 S. 2nd
St., Springfield, IL 62704.
Please mail settlement contracts to the assigned arbitrator.
Please mail all other forms to our Chicago office: 100 W.
Randolph St. #8-200, Chicago, IL 60601.
Unless
noted otherwise, the forms were last revised in 12/2004. Whenever
we create a new form, we allow six months from the revision date
for parties to make the transition. After that, outdated forms
may be returned to the filing party.
Copies of the
forms are available in the Chicago Reception Area and all Downstate
offices. If you would like to receive the forms by mail, contact
the Chicago Mail Room
(312/814-6633).
Please
be sure to fill in all fields. We must have complete mailing
addresses for all parties.
Word
Versions
The
Word forms are set up as fill-in-the-blank forms. You can tab through
the fields, type in your answers, print and save the document (go
to File/Save As).
You
can modify the forms. The Word forms are password-protected.
That means if the format suits you, type in your answers and don't
bother with the password. To change the formatting of a Word document,
go to Tools/Unprotect Document; type in the password (iwcc (lower
case)) and you can change the entire document. If you are having
problems, check the settings on File/Page Setup and select a letter-size
document with .5" margins.
You may reproduce
our forms as long as you create reasonably exact duplicates in layout,
font, size of type, etc. (Boxes and lines for check marks are both
OK.) Make sure your version of a form matches ours. You must
use colored paper if we use it; please match the color as closely
as possible. Forms that do not comply with our standards will be
returned to the filing party. The state seal can be reproduced on
the condition that the seal is used only on forms filed with the
Commission and for no other purpose, as provided by law.
If you don't
have Microsoft Word, you can download the free Word
Viewer, and then save the document in the software version you
do have.
Adobe/PDF
Versions
The PDF forms
are set up as fill-in-the-blank forms. You can tab through the fields,
type in your answers, and print.
PDF forms are
designed to fit different printers, so you should not have problems
with the formatting. If you don't see colored form fields
when you open a document, go to Adobe/Preferences/Forms, and click
the box to show the form fields in color.
If you can't
get the pdf forms to work, you may need to download a newer version
of the Adobe Reader. You
may download the Reader for free at www.adobe.com.
Accident Report
Forms
Section 6(b)
of the Workers' Compensation Act requires
employers (or insurers acting on their behalf) to send reports to
the Commission on all accidents involving more than three lost work
days. First reports on fatal accidents are due within two work days
after the death; reports on nonfatal cases shall be reported within
the month. A supplementary or subsequent report should be
made if it is determined that a permanent disability is involved.
There
are two versions of each report below. We will accept either
version. The IC45 and IC85 forms were created by the Commission;
the IA1 and IA2 forms were created by the International Association
of Industrial Accident Boards and Commissions, and are used in several
states. It may be more convenient for multi-state employers to use
the IAIABC forms.
OSHA
will accept the IC45 or the IA-1 form in lieu of the OSHA
Form 301; however, we cannot accept the OSHA form as an accident
report because the OSHA form does not contain all the information
required by state law.
If
possible, please send the reports electronically. It reduces
our data-entry work considerably, and will save you paper and postage.
For an information packet on electronic transmission, click
here. For more technical information, contact
Bennie Horton, Jr. (312/814-6179).
Please
mail the hard-copy accident reports to 701 S. Second Street, Springfield,
IL 62704.
To
modify the Word forms, go to Tools/Unprotect Document; type in the
password "iwcc" in lower case.
Arbitration Decision
Forms
Please submit
proposed decisions in Microsoft Word. Arbitrators may not
be able to read Word Perfect documents.
To make a check
mark, click your cursor in the box. In the
Findings section, on several occasions, a drop-down box will ask
you to choose a selection
(e.g, "$250,000 or 20 years" v. "$500,000 or 25 years");
click on the arrow to make your selection.
To
modify the Word forms, go to Tools/Unprotect Document; type in the
password "iwcc" in lower case.
Arbitration
Decision (revised 6/08) |
Word
|
19(b)
Arbitration Decision (revised 6/08) |
Word
|
19(b-1)
Arbitration Decision (revised 6/08) |
Word
|
Fatal--Arbitration
Decision (revised 6/08) |
Word
|
Nature
and extent--Arbitration Decision (revised 6/08) |
Word
|
IC34d
Decision (short form--appealable) (revised
11/08) |
Word
|
IC34o
Order (short form--interlocutory) |
Word
|
IC34s
Order Removing Settled Case From Call (revised
4/08) |
Word
|
Assessment
Forms
are
on the Assessments web page.
Case Management
Forms
To
modify the Word forms, go to Tools/Unprotect Document; type in the
password "iwcc" in lower case.
IC01 |
Application
for Adjustment of Claim
(Application for Benefits)
Click
here to read the guidelines provided for individuals filng
without an attorney. |
Word
|
Adobe
PDF
|
IC04
|
Notice
of Motion and Order |
Word
|
Adobe
PDF |
IC05 |
Settlement
Contract
Note: This form is on pink paper |
Word
|
Adobe
PDF |
IC06
|
Appearance
of Representative |
Word
|
Adobe
PDF |
IC07 |
Petition
for an Immediate Hearing under Sec. 19(b)
Note: This form is on blue paper |
Word
|
Adobe
PDF |
IC08
|
Response
to Petition for an Imm. Hearing under Sec. 19(b)
Note: This form is on goldenrod paper |
Word
|
Adobe
PDF |
IC09 |
Request
for Hearing |
Word
|
Adobe
PDF |
IC10
|
Attorney
Representation Agreement |
Word
|
Adobe
PDF |
IC11 |
Petition
for Review of Arbitration Decision
Note: This form is on orchid paper |
Word
|
Adobe
PDF |
IC11a
|
Petition
for Review of Arb. Decision under Sec. 19(b-1)
Note: This form is on orange paper |
Word
|
Adobe
PDF |
IC14
|
Petition
for Review under Sec. 19(h) or 8(a)
Note: This form is on aqua paper |
Word
|
Adobe
PDF |
IC14a
|
Petition
for Immediate Hearing under Sec. 19(b-1)
Note: This form is on gray paper |
Word
|
Adobe
PDF |
IC14b |
Response
to Petition for Imm. Hearing under Sec. 19(b-1)
Note: This form is on green paper |
Word
|
Adobe
PDF |
IC14d
|
Order
to Dismiss or Withdraw Petition under Sec. 19(b-1) |
Word
|
Adobe
PDF |
IC15
|
Proof
of Service
Note: This form is on pink paper |
|
Adobe
PDF |
IC16
|
Subpoena
(revised 11/21/08)
Note: This form is on yellow paper.
**Send materials requested by subpoena to the party requesting
them, not to the Commission.**
|
|
Adobe
PDF |
IC17 |
Motion
to Voluntarily Dismiss Case |
Word
|
Adobe
PDF |
IC19
|
Order
to Dismiss Case for Want of Prosecution |
Word
|
Adobe
PDF |
IC23 |
Petition
to Reinstate Case |
Word
|
Adobe
PDF |
IC26 |
Notice
of Change of Address (created 9/08) |
Word
|
Adobe
PDF |
IC27 |
Motion
to Dismiss Attorney of Record |
Word
|
Adobe
PDF |
IC28
|
Motion
to Withdraw as Attorney of Record |
Word
|
Adobe
PDF |
IC29
|
Stipulation
to Substitute Attorneys (revised 6/08) |
Word
|
Adobe
PDF |
IC31
|
Rehabilitation
Plan |
Word
|
Adobe
PDF |
IC32 |
Notice
of Rejection of Settlement Contract (revised 3/06) |
Word
|
Adobe
PDF |
IC33 |
Dedimus
Potestatem |
Word
|
Adobe
PDF |
IC36 |
Request
for Voluntary Arbitration |
Word
|
Adobe
PDF |
IC41
|
Arbitration
Information Sheet (revised 6/05) |
Word
|
Adobe
PDF |
ICTR
|
Transcript
Receipt Form (revised 1/08) |
Word
|
Adobe
PDF |
Self-Insurance
Forms
An Application
for Self-Insurance should be received at least 60 days prior
to the requested effective date of self-insurance. Please make sure
you submit all necessary materials with your application. Remember
you must keep your regular insurance coverage until you receive
written confirmation from the Commission authorizing you for the
self-insurance privilege. We will make every effort to process applications
promptly.
To
modify the Word forms, go to Tools/Unprotect Document; type in the
password "iwcc" in lower case.
IC50 |
Application
for Self-Insurance |
Word |
Adobe
PDF |
IC50s |
Application
for Self-Insurance for
Subsidiary or Affiliate of Current Self-Insured Company |
Word |
Adobe
PDF |
IC51 |
Petition
for Reconsideration of Application for Self-Insurance |
Word |
Adobe
PDF |
IC52 |
Self-Insurer's
Surety Bond |
Word |
Adobe
PDF |
IC53 |
Self-Insurer's
Surety Bond: General Purpose Rider |
Word |
Adobe
PDF |
IC55 |
Self-Insurer's
Surety Bond: Self-Administered Claims Endorsement |
Word |
Adobe
PDF |
IC56 |
Self-Insurer's
Surety Bond: Cancellation Amendment and Acknowledgement |
Word |
Adobe
PDF |
IC62 |
Self-Insurer's
Escrow Agreement |
Word |
Adobe
PDF |
IC63 |
Self-Insurer's
Escrow Agreement Amendment |
Word |
Adobe
PDF |
IC64 |
Self-Insurer's
Escrow Agreement: Release of Escrow Deposit |
Word |
Adobe
PDF |
IC72 |
Self-Insurer's
Agreement to Post Letter of Credit |
Word |
Adobe
PDF |
IC73 |
Self-Insurer's
Agreement to Post Letter of Credit: Schedule of Supplement |
Word |
Adobe
PDF |
IC80 |
Certificate
of Excess Insurance |
Word |
Adobe
PDF |
IC81 |
Multiple
Security Endorsement |
Word |
Adobe
PDF |
IC90 |
Parent
Guaranty Agreement in Connection with Self-Insurance Privilege
|
Word |
Adobe
PDF |
IC91 |
Parent
Guaranty Agreement in Connection with Self-Insurance Privilege:
Amendatory Schedule of Additional Employers |
Word |
Adobe
PDF |
Other Forms
To
modify the Word forms, go to Tools/Unprotect Document; type in the
password "iwcc" in lower case.
IC42 |
Request
for Investigation into Employer's Insurance Coverage (rev. 11/06)
|
Word
|
Adobe
PDF |
IC43 |
Injured
Workers' Benefit Fund: Request to Certify Lack of Insurance
Coverage (11/08) |
Word
|
Adobe
PDF |
IC44 |
Injured
Workers' Benefit Fund: Request for Benefits and Affidavit (6/08)
|
Word
|
Adobe
PDF |
ICAC |
Request
for Attorney Code Number (rev. 8/06) |
Word |
Adobe PDF |
ICPN
|
Workplace
Notice |
Word |
Adobe
PDF |
ICPNsp |
Workplace
Notice in Spanish |
Word |
Adobe
PDF |
Let us know if there is something we can do to the forms to
make them more convenient for you to use. But before you
write about formatting questions, please read the directions on
this page.
|