Application For IWCC Attorney Code Number

ILLINOIS WOR KER S COMPENS ATION COMMIS S ION 1 0 0 WES T RANDOLPH S TREET # 8 -2 00 CHICAGO, IL 60 6 01 -3 2 27 31 2 -8 14 - 65 00 WWW. IWCC.IL .GOV APPL ICATION FOR IWCC ATTOR NEY CODE NUMBER Att orney Firm Na m e Addres s S uit e/P.O. Box City, S ta t e, Zip Em a il Addres s Telephone Illinois AR DC R egis tra t ion Num ber R ETUR N TO: J ea nie Thom ps on Illinois Workers Com pens a tion Com m is sion Inform a t ion Depa rt m ent 1 00 Wes t R a ndolph Chica go, IL 6 06 0 1 iwccinfo@m a il.s ta t e.il.us Ass igned At t orney Code num ber Da t e As s igned 4 /20 0 5 American LegalNet, Inc. www.USCourtForms.com