Illinois Workers’ Compensation Commission

Appearance of Representative – Pro Se

ATTENTION. Please type or print. Complete all fields.
The Commission is required to validate your identity prior to allowing access into the CompFile system. 
 Refer to the Commission’s Guidelines for Individuals Filing a Case Without an Attorney for more information.

    	Case #         WC       
Employee/Petitioner

v.	     

       
Employer/Respondent

I hereby enter an appearance on my own behalf in the above matter.  

______________________________________________	
Signature of Petitioner	

     
Petitioner Name*

     		     
Street Address*		Telephone Number*

     		     
City, State, Zip code*	E-mail address (required)*

	

Signed and sworn to before me on  ______________________________

__________________________________________________________
Notary Public (Notarization is REQUIRED)

Rejection of Appearance

	Date _______________________

To:	__________________________________________________

__________________________________________________

__________________________________________________

Your appearance has been rejected for the following reason(s):

_____	No case number is listed.

_____	The wrong case number is listed.

_____	An attorney is listed as counsel, and he or she has not withdrawn or been dismissed.

_____	Other:  ________________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

If you have questions, please contact any Commission office (numbers are listed on bottom of page).  Once the Appearance of Representative - Pro Se is completed and notarized, you may return this form to the address listed below.  If you so choose, you may also bring this form into the Commission where staff will validate your identity and perform all necessary actions to provide you with the ability to set up your account in CompFile. 

Data Entry Unit
Illinois Workers’ Compensation Commission
69 W. Washington St., Suite 900
Chicago, IL 60602