Commission Review Board Complaint Form

ILLINOIS WORKERS' COMPENSATION COMMISSION COMMISSION REVIEW BOARD COMPLAINT FORM ATTENTION. Please type or print. _________________________________ Employee/Petitioner Case # ______ WC ____________ v. _________________________________ Employer/Respondent ____________________________________________________________________________________ Petitioner's name Street address City, State, Zip code ____________________________________________________________________________________ Date of birth Email address Last 4 digits of SSN or Alien Reg # ____________________________________________________________________________________ Employer's name Street address City, State, Zip code Briefly explain your complaint: The Privacy Act of 1979 (P.A. 93-570) prohibits the disclosure of information of a personal nature from the files of individuals without their consent. By signing below, you authorize the IWCC to access any and all records that relate to this complaint. ____________________________________________________________________________________ Signature Name (printed) Date ICCRB 12/12 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084 American LegalNet, Inc. www.FormsWorkFlow.com