Solomon Islands Finance

Jun 25 2017

IWCC FAQ #work #compensation #attorney


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 Incorrect or outdated forms will be returned to the filing party.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

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.

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

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 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.

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 .

Employer’s First Report of Injury(rev. 8/12)

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. 9/19/14)
Use these paragraphs with the decision forms below.

Arbitration Decision (rev. 2/10)

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 .

Application for Self-Insurance(rev. 1/12)

Public Employer’s Election to Self-Insure (12/14)

Application for Self-Insurance for Subsidiary or Affiliate of Current Self-Insured Company (rev. 5/09)

Petition for Reconsideration of Application for Self-Insurance (rev. 4/12)

Self-Insurer’s Surety Bond (rev. 5/09)

Self-Insurer’s Surety Bond: General Purpose Rider (rev. 5/09)

Self-Insurer’s Surety Bond: Self-Administered Claims Endorsement (rev. 5/09)

Self-Insurer’s Surety Bond: Cancellation Amendment and Acknowledgement (rev. 5/09)

Self-Insurer’s Escrow Agreement (rev. 5/09)

Self-Insurer’s Escrow Agreement Amendment (rev. 5/09)

Self-Insurer’s Escrow Agreement: Release of Escrow Deposit (rev. 5/09)

Self-Insurer’s Agreement to Post Letter of Credit (rev. 5/09)

Self-Insurer’s Agreement to Post Letter of Credit: Schedule of Supplement (rev. 5/09)

Certificate of Excess Insurance (rev. 5/10)

Multiple Security Endorsement (rev. 5/09)

Parent Guaranty Agreement in Connection with Self-Insurance Privilege (rev. 5/09)

Parent Guaranty Agreement in Connection with Self-Insurance Privilege: Amendatory Schedule of Additional Employers (rev. 5/09)

Other Forms

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

Injured Workers’ Benefit Fund: Request for Benefits and Affidavit (6/08)

Request for Information on Employer’s Insurance Coverage (12/12)

Request for Attorney Code Number (rev. 8/06)

Commission Review Board complaint form (created 12/21/12)

Workplace Notice (rev. 10/11)

Workplace Notice in Mandarin Chinese (rev. 11/11)

Powiadomienie do zamieszczenia w miejscu pracy(8/13)

Aviso Compensaci n a los Trabajadores(rev. 10/11)

Preferred Provider Program Mandatory Notice (6/13)

Aviso de Programa de Proveedor Preferido (6/13)

Preferred Provider Program Advisory Notice (6/13)

Aviso de Nuestro Programa de Proveedor Preferido de Compensaci n Laboral (6/13)

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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