USA: +1(669)289-8683 
Sign in
Adjustment of Claim: Explorer Air v. Pat Greene
Beginning a claim will require the attorney and the paralegal to communicate with a variety of people. The same information will be conveyed to all of them but the skill level of the recipient will be different. Learning to communicate effectively with opposing counsel, clerical staff at the workers’ compensation tribunal and especially with the client can prove difficult. Learning how to communicate is the key to full disclosure.
Why is it important to tailor your writing to the recipient?
Why should you go out of your way to write down to a client’s understanding level when it would be easier to educate them?
You represent Pat Greene. Draft the initial communication of the case, including the initial communication with opposing counsel, attorney appearance, and communication with physicians and workers’ compensation carriers. In addition to templates for the assignment, a sample application for adjustment of claim in Illinois is attached. Use this as a guide to create your own template for the fictitious Workers’ Compensation Board in Anytown, IL.
Click
here
to download the initial communication of the case, which is a checklist for required documents.
Click here to download a draft letter template for communicating with opposing counsel.
Click here to download a draft letter template for attorney appearance.
Click here to download a draft for release of information and authorization of physicians and carriers.
Click here to download the template for a sample adjustment form.
- Cite all sources using the Bluebook format.
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 1 Street address City, State, Zip code
______________________________________________________________________________________
Employer’s name Street address City, State, Zip code
Employee information: Social Security # _________________ 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 12/04 100 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
Disclosure of this information to the Commission is done voluntarily under 820 ILCS 305/6(b).
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
1 In 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.
2 This may be the date of the accident, last exposure, disability, or death.
3 If the employee has not returned to work, leave this space blank.
4 The 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.
5 The 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
- WC: Off
- OD: Off
- FatN: Off
- FATY: Off
- DOD:
- Pet:
- Resp:
- AccLocation:
- EmpName:
- EmpAddress:
- RespName:
- RespAddress:
- SSN:
- Male: Off
- Female: Off
- Married: Off
- Single: Off
- #Deps:
- Birthdate:
- AWW:
- AccDate:
- Oral: Off
- Writ: Off
- HowDidAccOccur:
- PartofBody:
- NatureofInjury:
- RTW date:
- 19bY: Off
- 19bN: Off
- TTDY: Off
- TTDN: Off
- PriorApps:
- SigDate:
- AttName:
- FirmName:
- AttAddress:
- AttCity:
- AttPhone:
- AttEmail:
- POSName:
- del: Off
- mailed: Off
- POSCity:
- POSTime:
- AM/PM: [AM]
- POSDate:
- POSAddresses:
Release of Information and Authorization
I, _______________________________ hereby consent to the release of:
(student inserts relevant language here)
to: Law Offices, 123 Main St., Anytown, IL 11001
For the purpose of: (student inserts relevant language here).
I understand that this release of information can be revoked by me at any time in writing. This release of information is valid for one year from the date of execution.
Signed:___________________________
Date:____________________________
Page 1 of 1
LGS2008 Worker’s Compensation Law
© 2013 South University
Law Offices
123 Main St.
Anytown, IL 11001
February 8, 2017
Workers Compensation Board
100 Maple St.
Anytown, IL 11001
Re:
Appearance, Pat Greene v. Explorer Air
To Whom It May Concern:
(Student inserts text here regarding attorney appearance)
Sincerely,
Name
Title
I hereby certify that a copy of the foregoing was served on (Insert parties who were served) via first class mail postage prepaid.
___________________________
Signature
___________________________
Date
Page 1 of 1
LGS2008 Worker’s Compensation Law
© 2013 South University
Law Offices
123 Main St.
Anytown, IL 11001
February 8, 2017
Ms. Anne Smith, Attorney at Law
234 Center St.
Anytown, IL 11001
Re:
Pat Greene v. Explorer Air
Dear Ms. Smith:
(Student inserts text here regarding attorney representation of client)
Sincerely,
Name
Title
Page 1 of 1
LGS2008 Worker’s Compensation Law
© 2013 South University
Checklist of Documents for Attorney
|
Item |
Date Sent |
|
1. |
Engagement letter to client from attorney. |
|
2. |
Release of information for medical records. |
|
3. |
Release of information to workers compensation carrier. |
|
4. |
Letter to defense counsel regarding representation. |
|
5. |
Appearance to court (if case is already in court). |
|
6. |
Draft claim for compensation |
Page 1 of 1
LGS2008 Worker’s Compensation Law
© 2013 South University
