image of people working IWCC  
link to home page
Pat Quinn, Governor
Pat Quinn, Governor

IWCC Links Skip to Content Skip to State Links

 Annual Report
 Appellate Court
 Opinions
 Assessments
 Basic Info
 Benefit Rates
 Calendars &
 Call Sheets
 Case Info
 Commission
 Decisions
 Contact
 Information
 español
 Forms
 Fraud

 Freedom of
 Information Act

 Frequently
 Asked
 Questions

 Handbook

 Injured Workers'
 Benefit Fund

 Insurance
 Jobs
 Links
 Medical Fees
 Meetings

 News

 Occupational
 Diseases Act

 Polski

 Rate
 Adjustment Fund
 Rules
 Self-Insurance
 Small Business
 Advisory

 Surchange
 Settlement
 Workers'
 Compensation
 Act
Inspector General

IWCC Forms

  Forms  

 

    
Attorney code numbers are required on all forms.  And please include your email address!  It will help expedite your case.

TABLE OF CONTENTS             

Accident report forms
Arbitration decision forms
Assessment forms 
Case management forms
Self-insurance forms 

Other forms
Forms password

 

Please mail to
Accident reports 4500 S. Sixth St. Frontage Road, Springfield, IL 62703-5118
Settlement contracts Assigned arbitrator or commissioner at his or her office.  Don't mail to the hearing site!
All other forms 100 W. Randolph St. #8-200, Chicago, IL 60601

Whenever we create a new form, we allow six months from the revision date for parties to make the transition.  Incorrect or outdated forms will be returned to the filing party. 

Note that the Social Security Number field was eliminated from the accident report, application, and settlement contract, a field to designate State employees was added, and the date of birth field is now mandatory on the application and settlement contract.

Please be sure to fill in all fields.  We must have complete mailing addresses for all parties.

Word Versions

The Word forms are set up as fill-in-the-blank forms. You can tab through the fields, type in your answers, print and save the document (go to File/Save As).

If the format suits you, tab through the fields and type in your answers. To modify the Word forms, click here. 

If you are having problems, check the settings on File/Page Setup and select a letter-size document with .5" margins. 

You may reproduce our forms as long as you create reasonably exact duplicates in layout, font, size of type, etc. (Boxes and lines for check marks are both OK.)  Make sure your version of a form matches ours. You must use colored paper if we use it; please match the color as closely as possible. Forms that do not comply with our standards will be returned to the filing party. The state seal can be reproduced on the condition that the seal is used only on forms filed with the Commission and for no other purpose, as provided by law.

If you don't have Microsoft Word, you can download the free Word Viewer, and then save the document in the software version you do have.


Modifying the Word forms

To modify the Word forms, go to Review/Protect document/Restrict formatting/Stop protection.  If you are using newer versions of Word, go to Tools/Unprotect document.  Password = iwcc (lower case)

If you want to re-protect the document, in order to tab through fields and have the drop-down menus work, click on “Editing restrictions” and you will be prompted to enter the password. You don’t have to enter the password. Click “ok.”

If you are using newer versions of Word, open the document and "save as" a docx file.

 

Adobe/PDF Versions

The PDF forms are set up as fill-in-the-blank forms. You can tab through the fields, type in your answers, and print.  PDF forms are designed to fit different printers, so you should not have problems with the formatting.  If you don't see colored form fields when you open a document, go to Adobe/Preferences/Forms, and click the box to show the form fields in color.

If you can't get the pdf forms to work, you may need to download a newer version of the Adobe Reader. You may download the Reader for free at www.adobe.com

To save your filled-in form, you will need to purchase Adobe Acrobat


Accident Report Forms

Section 6(b) of the Workers' Compensation Act requires employers (or insurers acting on their behalf) to send reports to the Commission on all accidents involving more than three lost work days. First reports on fatal accidents are due within two work days after the death; reports on nonfatal cases shall be reported within the month.  A supplementary or subsequent report should be made if it is determined that a permanent disability is involved. 

There are two versions of each report below.  We will accept either version.   The IC45 and IC85 forms were created by the Commission; the IA1 and IA2 forms were created by the International Association of Industrial Accident Boards and Commissions (IAIABC), used in manyl states.

OSHA will accept the IC45 or the IA-1 form in lieu of the OSHA Form 301; however, we cannot accept the OSHA form as an accident report because the OSHA form does not contain all the information required by state law.

If possible, please send the reports electronically.  It reduces our data-entry work considerably, and will save you paper and postage. For an information packet on electronic transmission, click here.  Send trading partner agreements and technical questions to Bennie Horton, Jr. (312/814-6179).

We are pleased to announce that, through an interagency agreement with the University of Illinois, we plan to convert the electronic process to IAIABC Release 3.  We will announce more information when it is available. 

Effective November 2011, in response to Supreme Court Order M.R. 138, the Commission no longer collects Social Security numbers. The field was eliminated from the accident report. Please update your forms.

Please mail the hard-copy accident reports to 4500 S. Sixth St. Frontage Road, Springfield, IL 62703-5118. 

To learn how to modify the Word forms, click here. 

IC45 Employer's First Report of Injury (rev. 8/12) Word.doc Adobe PDF
IC85 Employer's Supplementary Report of Injury  (rev. 8/12) Word.doc Adobe PDF
IA-1 IAIABC W.C. First Report of Injury  (rev. 11/11) Adobe PDF
IA-2 IAIABC W.C. Subsequent Report  (rev. 11/11) Adobe PDF




Arbitration Decision Forms

Please submit proposed decisions in Microsoft Word.   Arbitrators may not be able to read Word Perfect documents. 

To make a check mark, click your cursor in the box. In the Findings section, on several occasions, a drop-down box will ask you to choose a selection (e.g, "$250,000 or 20 years" v. "$500,000 or 25 years"); click on the arrow to make your selection.

Note:  The 2/10 decision forms are designed in tandem with the Arbitration Decision Paragraphs.  Copy, modify as necessary, and paste these paragraphs, as appropriate, into the Order section of the decision forms. 

To learn how to modify the Word forms, click here

Use the right form! Please note that the fact that an expedited (19(b) or 19(b-1)) petition was filed does not necessarily mean an expedited decision should be issued. Administratively, an expedited decision form is one in which the arbitrator or commissioner 1) does not address permanency; 2) rules only on TTD, TPD, maintenance, or medical benefits; and 3) orders that the case shall be returned to the call using the “not a bar” language.

Arbitration Decision Paragraphs (rev. 5/13)  
Use these paragraphs with the decision forms below.
Word.doc 
Arbitration Decision  (rev. 2/10) Word.doc 
19(b) Arbitration Decision   (rev. 2/10) Word.doc
19(b-1) Arbitration Decision   (rev. 2/10) Word.doc
Fatal--Arbitration Decision   (rev. 2/10) Word.doc
Nature and extent--Arbitration Decision   (rev. 2/10) Word.doc
IC34d   Decision (short form--appealable)   (rev. 11/08) Word.doc
IC34o   Order  (short form--interlocutory) (rev. 12/04) Word.doc
IC34s    Order Removing Settled Case From Call  (rev. 5/10) Word.doc

 

Assessment Forms

are on the Assessments web page.

 

Case Management Forms

To learn how to modify the Word forms, click here. 

IC01

Application for Adjustment of Claim  (rev. 5/12)
(Application for Benefits)

Click here to read the guidelines provided for individuals filing without an attorney.

Word.doc Adobe PDF 
IC04 Notice of Motion and Order  (rev. 4/11) Word.doc Adobe PDF
IC05

Settlement Contract (rev. 5/12)
Note: This form is on pink paper
 
**Submit one contract for every case number listed, plus one more copy**

Word.doc Adobe PDF
IC06 Appearance of Representative   (rev. 12/04) Word.doc Adobe PDF
IC07 Petition for an Immediate Hearing under Sec. 19(b) (rev. 12/04)
Note: This form is on blue paper
Word.doc Adobe PDF
IC08 Response to Petition for an Imm. Hearing under Sec. 19(b)  (rev. 12/04)
Note: This form is on goldenrod paper
Word.doc Adobe PDF
IC09 Request for Hearing  (rev. 2/10) Word.doc Adobe PDF
IC10 Attorney Representation Agreement (rev. 12/04) Word.doc Adobe PDF
IC11 Petition for Review of Arbitration Decision (rev. 12/04)
Note: This form is on orchid paper
Word.doc Adobe PDF
IC11a Petition for Review of Arb. Decision under Sec. 19(b-1) (rev. 12/04)
Note: This form is on orange paper
Word.doc Adobe PDF
IC14 Petition for Review under Sec. 19(h) or 8(a) (rev. 12/04)
Note: This form is on aqua paper
Word.doc Adobe PDF
IC14a Petition for Immediate Hearing under Sec. 19(b-1) (rev. 12/04)
Note: This form is on gray paper
Word.doc Adobe PDF
IC14b Response to Petition for Imm. Hearing under Sec. 19(b-1) (rev. 12/04)
Note: This form is on green paper
Word.doc Adobe PDF
IC14d Order to Dismiss or Withdraw Petition under Sec. 19(b-1) (rev. 12/04) Word.doc Adobe PDF
IC15 Proof of Service (rev. 12/04)
Note: This form is on pink paper
Adobe PDF
IC16 Subpoena  (rev. 3/13)
Note: This form is on yellow paper.
**Send materials requested by subpoena to the party requesting them, not to the Commission.**
Word.doc Adobe PDF
IC17 Motion to Voluntarily Dismiss Case   (rev. 12/04) Word.doc Adobe PDF
IC19 Order to Dismiss Case for Want of Prosecution (rev. 12/04) Word.doc Adobe PDF
IC23 Petition to Reinstate Case   (rev. 12/04) Word.doc Adobe PDF
IC25 Notice of Intent to File for Review in Circuit Court (7/13) Word.doc Adobe PDF
IC26 Notice of Change of Address (9/08) Word.doc Adobe PDF
IC27 Motion to Dismiss Attorney of Record (rev. 12/04) Word.doc Adobe PDF
IC28 Motion to Withdraw as Attorney of Record (rev. 12/04) Word.doc Adobe PDF
IC29 Stipulation to Substitute Attorneys  (rev. 8/12) Word.doc Adobe PDF
IC31 Rehabilitation Plan (rev. 12/04) Word.doc Adobe PDF
IC32 Notice of Rejection of Settlement Contract (rev. 3/06) Word.doc Adobe PDF
IC33 Dedimus Potestatem (rev. 12/04) Word.doc Adobe PDF
IC36 Request for Voluntary Arbitration   (rev. 12/04) Word.doc Adobe PDF
IC41

Arbitration Information Sheet  (rev. 8/12)

Word.doc Adobe PDF
ICTR Transcript Receipt Form  (revised 1/08) Word.doc Adobe PDF



Self-Insurance Forms

An Application for Self-Insurance should be received at least 60 days prior to the requested effective date of self-insurance. Please make sure you submit all necessary materials with your application. Remember you must keep your regular insurance coverage until you receive written confirmation from the Commission authorizing you for the self-insurance privilege. We will make every effort to process applications promptly.

Once you have received permission to self-insure, the Commission will send you an annual renewal form. Because each renewal will contain information particular to that self-insurer (e.g., security levels), we do not include the form in the list below. If you have questions about the renewal, please contact the Self-Insurance office.  For more information, see the Self-Insurance web page

To learn how to modify the Word forms, click here.  

IC50 Application for Self-Insurance   (rev. 1/12) Word Adobe PDF
IC50s Application for Self-Insurance for Subsidiary or Affiliate of Current Self-Insured Company (rev. 5/09) Word Adobe PDF
IC51 Petition for Reconsideration of Application for Self-Insurance (rev. 4/12) Word Adobe PDF
IC52 Self-Insurer's Surety Bond  (rev. 5/09) Word Adobe PDF
IC53 Self-Insurer's Surety Bond: General Purpose Rider (rev. 5/09) Word Adobe PDF
IC55 Self-Insurer's Surety Bond: Self-Administered Claims Endorsement  (rev. 5/09) Word Adobe PDF
IC56 Self-Insurer's Surety Bond: Cancellation Amendment and Acknowledgement  (rev. 5/09) Word Adobe PDF
IC62 Self-Insurer's Escrow Agreement  (rev. 5/09) Word Adobe PDF
IC63 Self-Insurer's Escrow Agreement Amendment  (rev. 5/09) Word Adobe PDF
IC64 Self-Insurer's Escrow Agreement: Release of Escrow Deposit  (rev. 5/09) Word Adobe PDF
IC72 Self-Insurer's Agreement to Post Letter of Credit  (rev. 5/09) Word Adobe PDF
IC73 Self-Insurer's Agreement to Post Letter of Credit: Schedule of Supplement  (rev. 5/09) Word Adobe PDF
IC80 Certificate of Excess Insurance  (rev. 5/10) Word Adobe PDF
IC81 Multiple Security Endorsement  (rev. 5/09) Word Adobe PDF
IC90 Parent Guaranty Agreement in Connection with Self-Insurance Privilege  (rev. 5/09) Word Adobe PDF
IC91 Parent Guaranty Agreement in Connection with Self-Insurance Privilege: Amendatory Schedule of Additional Employers  (rev. 5/09) Word Adobe PDF

Other Forms

To learn how to modify the Word forms, click here. 

IC44 Injured Workers' Benefit Fund: Request for Benefits and Affidavit (6/08) Word Adobe PDF
IC46 Request for Information on Employer's Insurance Coverage (12/12) Word Adobe PDF
ICAC Request for Attorney Code Number (rev. 8/06) Word Adobe PDF
ICCRB Commission Review Board complaint form (created 12/21/12) Word Adobe PDF
ICPN Workplace Notice (rev. 10/11) Word Adobe PDF
ICPNmc Workplace Notice in Mandarin Chinese (rev. 11/11) Word Adobe PDF
ICPNp Powiadomienie do zamieszczenia w miejscu pracy  (8/13) Word Adobe PDF
ICPNsp Aviso Compensación a los Trabajadores    (rev. 10/11) Word Adobe PDF
PPP Preferred Provider Program Mandatory Notice (6/13) Word
PPPsp Aviso de Programa de Proveedor Preferido (6/13) Word
PPPadv Preferred Provider Program Advisory Notice (6/13) Word
PPPadvsp Aviso de Nuestro Programa de Proveedor Preferido de Compensación Laboral (6/13) Word

Note: We do not have a form with which sole proprietors may opt out of workers' compensation insurance. Ask your insurer or attorney.

Let us know if there is something we can do to the forms to make them more convenient for you to use. But before you write about formatting questions, please read the directions on this page. 

 

Copyright 2002 State of Illinois   Privacy Statement   Contact Us