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This is a Illinois form that can be used for Workers Comp.
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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 FATAL 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. The matter was heard by the Honorable , Arbitrator of the Commission, in the city of , on . 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 Decedent's employment by Respondent? What was the date of the accident? Was timely notice of the accident given to Respondent? Is Decedent's current condition of ill-being causally related to the injury? What were Decedent's earnings? What was Decedent's age at the time of the accident? What was Decedent's marital status at the time of the accident? Who was dependent on Decedent at the time of death? Were the medical services that were provided to Decedent reasonable and necessary? Has Respondent paid all appropriate charges for all reasonable and necessary medical services? What compensation for permanent disability, if any, is due? Should penalties or fees be imposed upon Respondent? Is Respondent due any credit? Other ICArbDecFatal 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, , Respondent was operating under and subject to the provisions of the Act. exist between Decedent and Respondent. On this date, an employee-employer relationship did On this date, Decedent did sustain an accident that arose out of and in the course of employment. given to Respondent. Timely notice of this accident was Decedent's death is causally related to the accident. ; the average weekly wage was $ with children under 18. . In the year preceding the injury, Decedent earned $ On the date of accident, Decedent was Respondent has years of age, single 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 TTD, $ $ for other benefits, for a total credit of $ . Respondent is entitled to a credit of $ The Arbitrator finds that Decedent died on the Act, including . ORDER under Section 8(j) of the Act. , leaving survivor(s), as provided in Section 7(a) of 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 party files a Petition for Review within 30 days after receipt of this decision, and 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 ICArbDecFatal p. 2 American LegalNet, Inc. www.FormsWorkFlow.com