8. Petitioner claims to be entitled to (Attach a sheet if necessary to list additional periods.)
TTD period(s): ______________________________________________________ , representing _______ weeks.
First day of lost time through Last day of lost time
Respondent agrees ____ disputes ____ and claims _______________________________________________
TPD period(s): ________________________________________________________ , representing _______ weeks.
First day through Last day
Respondent agrees ____ disputes ____ and claims _______________________________________________
Maintenance period(s): _________________________________________________ , representing _______ weeks.
First day through Last day
Respondent agrees ____ disputes ____ and claims _______________________________________________
9. Respondent claims it paid $ __________________ in TTD, $ __________________ in TPD,
$ _________________ in maintenance, $ _________________ in nonoccupational indemnity disability benefits,
and $ __________________ in other benefits, for which credit may be allowed under §8(j) of the Act.
Petitioner agrees ____ disputes ____ and claims ___________________________________________________
10. The nature and extent of the injury is ____ is not ____ in dispute.
11. Petitioner claims to be entitled to penalties/attorney’s fees under §19(k) ___ §19(l) ___ and/or §16 ___.
Petitioner has ____ has not ____ filed a penalty petition.
12. A petition for attorney’s fees by a former attorney is ____ is not ____ pending. Petitioner’s attorney has
notified the former attorney of the date of this hearing.
13. Other issues, not listed above, are: ______________________________________________________________________
14. STENOGRAPHIC STIPULATION. Both parties agree that if either party files a Petition for Review of
Arbitration Decision and orders a transcript of the hearings, and if the Commission's court reporter does not
furnish the transcript within the time limit set by law, the other party will not claim the Commission lacks
jurisdiction to review the arbitration decision because the transcript was not filed timely.
A written decision, including findings of fact and conclusions of law, is requested pursuant to Section 19(b).
__________________________________________________ ________________________________________________
Date submitted Name of Respondent's insurance or service company
__________________________________________________ ________________________________________________
Signature of Petitioner or Petitioner's attorney Signature of Respondent or Respondent's attorney
__________________________________________________ ________________________________________________
Attorney’s name and IC code # Attorney’s name and IC code #
__________________________________________________ ________________________________________________
Name of law firm Name of law firm
__________________________________________________ ________________________________________________
Street address Street address
__________________________________________________ ________________________________________________
City, State, Zip code City, State, Zip code
______________________ ___________________________ _____________________ _________________________
Telephone number Email address Telephone number Email address
NOTE: The arbitration decision will be sent by certified mail to the addresses listed above.
IC9 p. 2