Injured Workers Benefit Fund - Request For Benefits And Affidavit {IC44}

IC44 - INJURED WORKERS' BENEFIT FUND: REQUEST FOR BENEFITS AND AFFIDAVIT. This form is used by an injured employee (petitioner) in Illinois to request payment of workers’ compensation benefits from the Injured Workers’ Benefit Fund (IWBF) when their employer failed to carry workers’ compensation insurance. The form must be completed and signed under oath by the petitioner, affirming that the IWBF was named as a respondent in their case and that the Illinois Workers’ Compensation Commission issued a monetary award in their favor. The petitioner must provide the date of the award, the amount granted (excluding penalties and attorney’s fees), and documentation showing the award. The form also requires the petitioner to declare how much, if any, of the awarded benefits the employer has already paid and how much remains unpaid. By submitting this form and receiving funds from the IWBF, the petitioner acknowledges that they will not be entitled to receive any additional monetary award from the IWBF for the same case. The form must be notarized and includes the petitioner’s signature, mailing address, and Social Security number for verification. www.FormsWorkflow.com