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.

Form NameForm Ic1
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesic01FORM ic01form

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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 #



(Office use only)






Location of accident ________________________


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 ______



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



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:

Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084


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

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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.

Filling out section 1 of Form Ic1

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!

Filling out segment 2 in Form Ic1

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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