Breadcrumb

Forms

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

TABLE OF CONTENTS

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 Incorrect or outdated forms will be returned to the filing party.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.

Arbitrator evaluation form

Assessment Forms are on the Assessments web page.

Mailing Addresses

Accident Reports

4500 S. Sixth Street Rd
Springfield, IL 62703-5118

Settlement Contracts

Send settlement contracts to the assigned arbitrator or commissioner.

Don't mail settlement contracts to the hearing site!

All other forms

100 W Randolph St STE 8-200
Chicago IL 60601-3227

Accident Reporting

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 many 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.

Electronic Transmission Information

Send trading partner agreements and technical questions to wcc.edi@illinois.gov

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 Street Rd
Springfield, IL 62703-5118

Learn how to modify Word forms.

Accident Report Forms

  • 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 Information

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.
Modifying Word forms

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.

Arbritation Decision Forms

  • Arbitration Decision Paragraphs (rev. 9/19/14) [Word.doc]
    Use these paragraphs with the decision forms below.
  • 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]

Case Management Forms

Learn how to modify Word forms.

  • IC01 Application for Adjustment of Claim (rev. 5/12) (Application for Benefits) [Word.doc] [Adobe PDF]
    Guidelines for individuals filing without an attorney.
  • IC04 Notice of Motion and Order (rev. 4/11) [Word.doc] [Adobe PDF]
  • IC05 Settlement Contract (rev. 5/12) [Word.doc] [Adobe PDF]
    Note: This form is on pink paper
    Submit one contract for every case number listed, plus one more copy
  • IC06 Appearance of Representative (rev. 12/04) [Word.doc] [Adobe PDF]
  • IC07 Petition for an Immediate Hearing under Sec. 19(b) (rev. 12/04) [Word.doc] [Adobe PDF]
    Note: This form is on blue paper
  • IC08 Response to Petition for an Imm. Hearing under Sec. 19(b) (rev. 12/04) [Word.doc] [Adobe PDF]
    Note: This form is on goldenrod paper
  • 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) [Word.doc] [Adobe PDF]
    Note: This form is on orchid paper
  • IC11a Petition for Review of Arb. Decision under Sec. 19(b-1) (rev. 12/04) [Word.doc] [Adobe PDF]
    Note: This form is on orange paper
  • IC14 Petition for Review under Sec. 19(h) or 8(a) (rev. 12/04) [Word.doc] [Adobe PDF]
    Note: This form is on aqua paper
  • IC14a Petition for Immediate Hearing under Sec. 19(b-1) (rev. 12/04) [Word.doc] [Adobe PDF]
    Note: This form is on gray paper
  • IC14b Response to Petition for Imm. Hearing under Sec. 19(b-1) (rev. 12/04) [Word.doc] [Adobe PDF]
    Note: This form is on green paper
  • 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) [Word.doc] [Adobe PDF]
    Note: This form is on pink paper
  • IC16 Subpoena(rev. 04/15) [Word.doc] [Adobe PDF]
    Note: This form is on yellow paper.
    Send materials requested by subpoena to the party requesting them, not to the Commission.
  • 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 Information

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.

Learn how to modify Word forms.

Self-Insurance Forms

  • IC50 Application for Self-Insurance (rev. 1/12) [Word] [Adobe PDF]
  • IC50e Public Employer's Election to Self-Insure (12/14) [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

Learn how to modify Word forms.

  • 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]

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. You may modify Word forms.

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.

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.

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.