Response To Petition For An Immediate Hearing Under Section 19b Of The Act {IC8}

ILLINOIS WORKERS COMPENSATION COMMISSION RESPONSE TO PETITION FOR AN IMMEDIATE HEARING UNDER SECTION 19(b) OF THE ACT _______________________________________________ Case # ________ WC ____________________ Employee/Petitioner v. _______________________________________________ Employer/Respondent On ____________________ , the respondent received the petitioners Petition for an Immediate Hearing Under Section 19(b) of the Act . By law, the respondent must reply within 15 days of receipt. The respondent makes the following claims: Y ES N O The petitioner was an employee of the respondent on the date of the alle ged accident or exposure.____ ____The alleged accident or disease arose out of and in the course of employ ment. ____ ____The respondent indicates its agreement or disagreement with the petition ers allegations regarding each of the following items: A GREE D ISAGREE 1. Date, time, and location of the accident ____ ____2. Description of the accident ____ ____3. Nature of the injury ____ ____4. Notice of the accident ____ ____5. Employers refusal to pay proper compensation and/or medical benefits ____ ____6. Treatment of employee by a medical provider selected by the employer ____ ____7. Medical providers and treatments ____ ____8. Medical bills in dispute ____ ____9. Employers receipt of a statement from a medical provider indicating emp loyee cannot work____ ____10. Last payment of temporary total disability benefits ____ ____11. Unsuccessful effort to resolve dispute between employee and employer ____ ____On the back of this form, please explain each area of disagreement. ______________________________________________________ ______________________________________________________ Signature of respondent or respondents attorney Date Name (please print; attorneys, please include IC code #) IC8 12/04 100 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.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2EXPLANATION: PROOF OF SERVICE 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 at ___________ on ___________________ to each party at the address(es) listed below. ____________________________________________ Signature of person completing Proof of Service Signed and sworn to before me on __________________ ___________________________________________ Notary Public American LegalNet, Inc.IC8 page 2 www.USCourtForms.com