Arbitration Decision Nature And Extent Only

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 NATURE AND EXTENT ONLY Case # Employee/Petitioner WC v. Employer/Respondent Consolidated cases: The only disputed issue is the nature and extent of the injury. An Application for Adjustment of Claim was filed in this matter, and a Notice of Hearing was mailed to each party. The matter was heard by the Honorable , Arbitrator of the Commission, in the city of , on . By stipulation, the parties agree: On the date of accident, , Respondent was operating under and subject to the provisions of the Act. On this date, the relationship of employee and employer did exist between Petitioner and Respondent. On this date, Petitioner sustained an accident that arose out of and in the course of employment. Timely notice of this accident was given to Respondent. Petitioner's current condition of ill-being is causally related to the accident. In the year preceding the injury, Petitioner earned $ At the time of injury, Petitioner was , and the average weekly wage was $ with children under 18. . years of age, single Necessary medical services and temporary compensation benefits have been provided by Respondent. Respondent shall be given a credit of $ for TTD, $ $ for other benefits, for a total credit of $ . for TPD, $ for maintenance, and ICArbDecN&E 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 After reviewing all of the evidence presented, the Arbitrator hereby makes findings regarding the nature and extent of the injury, and attaches the findings to this document. ORDER Respondent shall pay Petitioner the sum of $ /week for a further period of Section of the Act, because the injuries sustained caused . Respondent shall pay Petitioner compensation that has accrued from remainder of the award, if any, in weekly payments. through weeks, as provided in , and shall pay the 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 [or use attached form: Arbitration Decision Order Paragraphs] RULES REGARDING APPEALS Unless a Petition for Review is filed within 30 days after receipt of this decision, and a review is perfected 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 ICArbDecN&E p.2 American LegalNet, Inc. www.FormsWorkFlow.com