Form Ic1 – Fill Out and Use This PDF

The IC1 form, officially known as the Illinois Workers' Compensation Commission Application for Adjustment of Claim, serves as a crucial initial step for employees seeking benefits under the Workers' Compensation or Occupational Diseases Acts. This form requires detailed information about the incident, including the date, location, nature of the injury, and employment details, to be completed accurately and submitted in triplicate. Click the button below to ensure your rights are protected by filling out the form meticulously.

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Form Ic1 PDF Details

In the realm of workplace incidents and the subsequent journey towards claiming benefits, the Illinois Workers' Compensation Commission Application for Adjustment of Claim, succinctly referred to as the IC1 form, stands out as a vital document. Aimed primarily at employees who have endured injuries or illnesses due to their job, this application serves as the starting point in seeking workers' compensation. It meticulously collects all pertinent data, right from the basics of the employee and employer information to the specifics of the accident or exposure that led to the injury or disease. The form mandates a detailed account of the incident, including the date, how it occurred, the nature of the injury or disease, and its impact on the injured party's body, alongside the claimant's current employment status in regards to receiving temporary total disability benefits. The consideration for fatal cases adds a layer of complexity, ensuring the document covers a wide spectrum of situations. Furthermore, the IC1 form highlights the necessity of proper completion and underscores the legal significance of the information provided by including sections for petitioner and attorney signatures, thereby emphasizing its role not merely as a formality but as a critical legal document. With the requirement to file three copies, the protocol points towards an intricate process designed to ensure thorough vetting and processing by the Workers' Compensation Commission. The inclusion of a Proof of Service section further delineates the procedural steps required to navigate the Illinois workers' compensation system effectively.

Question	Answer
Form Name	Form Ic1
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	ic01FORM ic01form

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ILLINOIS WORKERS’ COMPENSATION COMMISSION

APPLICATION FOR ADJUSTMENT OF CLAIM (APPLICATION FOR BENEFITS)

ATTENTION. Please type or print. Answer all questions. File three copies of this form.

Workers' Compensation Act ___ Occupational Diseases Act ___ Fatal case? No ___ Yes ___ Date of death __________

_________________________________	Case #
Employee/Petitioner	(Office use only)
v.
_________________________________	Location of accident ________________________
Employer/Respondent	or last exposure	City, State

______________________________________________________________________________________

Injured employee's name 1Street addressCity, State, Zip code

______________________________________________________________________________________


Employer's name	Street address			City, State, Zip code
Employee information: State Employee? Yes ____		No ____	Male ____ Female ____		Married ____ Single ____
# Dependents under age 18 ______	Birthdate	_____________		Average weekly wage $ _________________
Date of accident 2 _______________________		The employer was notified of the accident orally ____ in writing ____

How did the accident occur? ____________________________________________________________________________

What part of the body was affected? ______________________________________________________________________

What is the nature of the injury? ___________________________________	Return-to-work date 3 ________________
Is a Petition for an Immediate Hearing attached? Yes ____ No ____
Is the injured employee currently receiving temporary total disability benefits?	Yes ____ No ____

If a prior application was ever filed for this employee, list the case number and its status ______________________________

ATTENTION, PETITIONER. This is a legal document. Be sure all blanks are completed correctly and you understand the statements before you sign this. Refer to the Commission's Handbook on Workers' Compensation and Occupational Diseases 4 for more information.

_________________________________________	__________________________
Signature of petitioner	Date

APPEARANCE OF PETITIONER'S ATTORNEY

Please attach a copy of the Attorney Representation Agreement.

_________________________________________	____________________________________________
Signature of attorney	Street address
_________________________________________	____________________________________________
Attorney’s name and IC code # 5 (please print)	City, State, Zip code
_________________________________________	___________________	_______________________
Firm name	Telephone number	E-mail address

IC1 5/12 100 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

PROOF OF SERVICE

If the person who signed the Proof of Service is not an attorney, this form must be notarized.

If you prefer, you may submit the front of this application form with the Proof of Service on a separate page.

I, _______________________________ , affirm that I delivered _____ mailed with proper postage _____

in the city of _________________________________ a copy of this form

at ___________ on ___________________ to the respondent listed on this application and to each

additional party, if any, at the address listed below.

____________________________________________

Signature of person completing Proof of Service

Signed and sworn to before me on ________________

___________________________________________

Notary Public

1In most cases, the injured employee files this application and is referred to as the petitioner. If the injury was fatal, or if the worker is a minor or incapacitated, another person (as allowed by law) may file. In those cases, the person filing the application is the petitioner, and the worker is referred to as the injured employee. Please complete information related to age, etc., for the injured employee.

2This may be the date of the accident, last exposure, disability, or death.

3If the employee has not returned to work, leave this space blank.

4The Commission publishes a handbook that explains the workers' compensation system. If you would like a copy, please call any of the Commission offices listed on the other side of this form.

5The Commission assigns code numbers to attorneys who regularly practice before it. To obtain or look up a code number, contact the Information Unit in Chicago or any of the downstate offices at the telephone numbers listed on this form.

IC1 page 2

How to Edit Form Ic1 Online for Free

Any time you wish to fill out Form Ic1, you won't have to install any software - simply try our online PDF editor. In order to make our editor better and less complicated to work with, we continuously design new features, with our users' feedback in mind. This is what you will have to do to start:

Step 1: Click on the "Get Form" button above. It's going to open up our pdf editor so that you can begin filling out your form.

Step 2: As soon as you launch the tool, you will find the document ready to be filled out. In addition to filling out different blanks, you can also do many other things with the file, specifically writing custom text, editing the initial textual content, inserting images, signing the document, and much more.

So as to finalize this PDF form, ensure you provide the right details in every single field:

1. When completing the Form Ic1, be sure to incorporate all necessary fields in its associated form section. This will help to hasten the work, allowing your information to be handled quickly and appropriately.

2. Once your current task is complete, take the next step – fill out all of these fields - v EmployerRespondent Injured, Date, APPEARANCE OF PETITIONERS ATTORNEY, Please attach a copy of the, Signature of attorney Attorneys, please print, City State Zip code, Telephone number, Email address, and Street address with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

3. This third step is going to be straightforward - complete all the form fields in I affirm that I delivered to complete this part.

I affirm that I delivered, I affirm that I delivered, and I affirm that I delivered in Form Ic1

Those who work with this PDF frequently make errors when filling out I affirm that I delivered in this area. Make sure you go over everything you type in right here.

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Form Ic1 – Fill Out and Use This PDF

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