Motion To Voluntarily Dismiss {IC17}

ILLINOIS 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 ORDER 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: www.iwcc.il.govDownstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084 American LegalNet, Inc. www.USCourtForms.com