Arbitration Case Information Sheet {IC41}

ILLINOIS WORKERS' COMPENSATION COMMISSION ARBITRATION CASE INFORMATION SHEET ATTENTION. Please complete this form, have both parties sign it, and place it in the arbitrator's message box next to the hearing room door or other area designated by the arbitrator. Do not interrupt the hearings. Be as specific as possible. You must see the arbitrator if your case is above the red line. _____________________________________________ Employee/Petitioner Arbitrator ________________________________ Case # ________ WC ________________________ v. Today's date ________________________________ _____________________________________________ Employer/Respondent Status call date and line # ______________________ Please check the appropriate box. Petitioner is receiving TTD. Petitioner is still treating. Name of doctor/clinic: ______________________________________________________ Date and nature of last treatment: _____________________________________________________________________ Petitioner is receiving vocational rehabilitation/job placement services. Date and nature of last service: ________________________________________________________________________ Deposition scheduled for _____________________ We expect to be ready for trial by _____________________ Tentative settlement reached. We will submit contract for approval by ____________________________ Request for approval of Medicare set-aside was submitted on ____________________________ The case will be ready for trial by ____________________________ The case was partially tried on __________________________ Next trial date is __________________________ Other (explain) ______________________________________________________________________________________ _______________________________________________ Signature of petitioner's attorney ___________________________________________ Signature of respondent's attorney _______________________________________________ Name of petitioner's attorney (please print) ___________________________________________ Name of respondent's attorney (please print) _______________________________________________ Email address ___________________________________________ Email address One-sided or ex parte communication is prohibited. Any correspondence sent to the Commission related to a pending matter must be sent to all parties at the time it is sent to the Commission, and must list the parties to whom copies have been sent. IC41 8/12 100 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