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Yellow Corporation, et.al., Bankruptcy Notice

Medical Fee Advisory Board Subcommittee on ASC Billing Practices

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 Incorrect or outdated forms will be returned to the filing party.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

Settlement Contracts

All settlement contracts must be drafted in CompFile and filed electronically.

1) Pro se settlements: A settlement involving a pro se petitioner requires an in-person hearing. These hearings are currently being scheduled virtually via Webex. Draft and submit pro se settlement contracts in CompFile. You can then contact the assigned Arbitrator to schedule the hearing.

2) "No-App" settlements: A settlement in a case that not been previously filed with the IWCC and has no case number. Draft "No-App" settlement contracts in CompFile and indicate that you do not have a case number. Upon submission of the settlement contract for approval, a case number and Arbitrator will be assigned to the case.

All forms related to the management of workers' compensation cases must be submitted in CompFile.

All other forms should be mailed to:

Illinois Workers' Compensation Commission
69 W Washington Street
Suite 900
Chicago, IL 60602

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.

Beginning on June 14, 2019, Illinois is now requiring all accident reports to be submitted in the IAIABC's 3.1 XML Standard. Please see the EDI Implementation Section of our website for more details.

Effective November 2011, in response to Supreme Court Order M.R. 138, the IWCC no longer collects Social Security Numbers. The field was eliminated from all required reporting. Please update your forms.

Arbitration Decision Information

Please submit proposed decisions in Microsoft Word. Arbitrators may not be able to read Word Perfect documents. Proposed decisions are to be submitted via email directly to the Arbitrator.

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.

Arbitration 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

Forms related to the management of workers' compensation cases before the IWCC must be submitted electronically in CompFile, the IWCC's electronic filing and case management system. Learn more about CompFile.

Most case management forms must be completed by the filing party and then attached in CompFile. The IC01 Application for Adjustment of Claim, IC04 Notice of Motion and Order, and IC05 Settlement Contract are the exceptions. These three forms are completed directly in CompFile.

Prior to CompFile, the IWCC required that certain forms be filed on colored paper. This is no longer required in CompFile.

The IWCC provides the case management forms in both Word and PDF format. The IWCC recommends using the PDF format when attaching forms in CompFile. Learn how to modify Word forms.

FOR REFERENCE ONLY. The following forms are provided for reference only. These three forms are completed directly in CompFile.

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

  • IC50e Public Employer's Election to Self-Insure (12/14) [Word] [Adobe PDF]
  • IC51 Petition for Reconsideration of Application for Self-Insurance (rev. 2/22) [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]
  • 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]
  • 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]
  • ICAC Request for Attorney Code Number Please note: This form has been retired. All new Code Number assignments are handled via CompFile.
  • 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.

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Contact Information

Chicago: 312-814-6500

Springfield: 217-785-7087

Collinsville: 618-346-3484

Peoria: 312-814-6500

Rockford: 312-814-6500 If you intend to visit our Peoria or Rockford office, please call first to make sure the office is open.

TDD/TTY Support Line: 866-383-4370

Support: wcc.compfile@illinois.gov

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