Arbitration Decision 19(b-1)

STATE OF ILLINOIS ) )SS. Injured Workers' Benefit Fund (§4(d)) Rate Adjustment Fund (§8(g)) Second Injury Fund (§8(e)18) None of the above COUNTY OF ) ILLINOIS WORKERS' COMPENSATION COMMISSION ARBITRATION DECISION 19(b-1) Case # Employee/Petitioner WC v. Employer/Respondent Consolidated cases: An Application for Adjustment of Claim was filed in this matter, and a Notice of Hearing was mailed to each party. Petitioner filed a Petition for an Immediate Hearing Under Section 19(b-1) of the Act on . Respondent filed a Response on . The Honorable , Arbitrator of the Commission, held a pretrial conference on , and a trial on , in the city of . After reviewing all of the evidence presented, the Arbitrator hereby makes findings on the disputed issues checked below, and attaches those findings to this document. DISPUTED ISSUES A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. Was Respondent operating under and subject to the Illinois Workers' Compensation or Occupational Diseases Act? Was there an employee-employer relationship? Did an accident occur that arose out of and in the course of Petitioner's employment by Respondent? What was the date of the accident? Was timely notice of the accident given to Respondent? Is Petitioner's current condition of ill-being causally related to the injury? What were Petitioner's earnings? What was Petitioner's age at the time of the accident? What was Petitioner's marital status at the time of the accident? Were the medical services that were provided to Petitioner reasonable and necessary? Has Respondent paid all appropriate charges for all reasonable and necessary medical services? Is Petitioner entitled to any prospective medical care? What temporary benefits are in dispute? Maintenance TTD TPD Should penalties or fees be imposed upon Respondent? Is Respondent due any credit? Other ICArbDec19(b-1) 2/10 100 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 FINDINGS On the date of accident, On this date, Petitioner did , Respondent was operating under and subject to the provisions of the Act. exist between Petitioner and Respondent. On this date, an employee-employer relationship did Timely notice of this accident was sustain an accident that arose out of and in the course of employment. given to Respondent. causally related to the accident. ; the average weekly wage was $ with children under 18. . Petitioner's current condition of ill-being is In the year preceding the injury, Petitioner earned $ On the date of accident, Petitioner was Respondent has years of age, single for TTD, $ . paid all reasonable and necessary charges for all reasonable and necessary medical services. for TPD, $ for maintenance, and $ Respondent shall be given a credit of $ for other benefits, for a total credit of $ Respondent is entitled to a credit of $ ORDER under Section 8(j) of the Act. Insert appropriate order text here. You may use and modify the appropriate text from the list of boilerplate paragraphs at http://www.iwcc.il.gov/arbordertext.doc In no instance shall this award be a bar to subsequent hearing and determination of an additional amount of temporary total disability, medical benefits, or compensation for a permanent disability, if any. RULES REGARDING APPEALS Unless a party 1) files a Petition for Review within 30 days after receipt of this decision; and 2) certifies that he or she has paid the court reporter $ or the estimated cost of the arbitration transcript and attaches a copy of the check to the Petition; and 3) perfects a review in accordance with the Act and Rules, then this decision shall be entered as the decision of the Commission. STATEMENT OF INTEREST RATE If the Commission reviews this award, interest at the rate set forth on the Notice of Decision of Arbitrator shall accrue from the date listed below to the day before the date of payment; however, if an employee's appeal results in either no change or a decrease in this award, interest shall not accrue. ___________________________________ Signature of Arbitrator Date ICArbDec19(b-1) p. 2 American LegalNet, Inc. www.FormsWorkFlow.com