Illinois form 45: employer's first report of injury




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ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY

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Employer's FEIN

Date of report

Case or File #

Is this a lost workday case?

     

     

     



Employer's name

Doing business as

     

     

Employer's mailing address

Employer’s email address

     

     

Nature of business or service

SIC code

     

     

Name of workers' compensation carrier/admin.

Policy/Contract #

Self-insured?

     

     



Employee's full name

Birthdate

     

     

Employee's mailing address

Employee's e-mail address

     

     

Gender

Marital status

# Dependents

Employee's average weekly wage





     

     

Job title or occupation

Date hired

     

     

Time employee began work

Date and time of accident

Last day employee worked

      

           

     

If the employee died as a result of the accident, give the date of death.

Did the accident occur on the employer's premises?

     



Address of accident

     

What was the employee doing when the accident occurred?

     

How did the accident occur?

     

What was the injury or illness? List the part of body affected and explain how it was affected.

     

What object or substance, if any, directly harmed the employee? 

     

Name and address of physician/health care professional

     

If treatment was given away from the worksite, list the name and address of the place it was given.

     

Was the employee treated in an emergency room?

Was the employee hospitalized overnight as an inpatient?





Report prepared by

Signature

Title and telephone #

Email address

     




     

     

Please send this form to: ILLINOIS WORKERS' COMPENSATION COMMISSION 4500 S. SIXTH ST. FRONTAGE ROAD SPRINGFIELD, IL 62703-5118

By law, employers must keep accurate records of all work-related injuries and illness (except for certain minor injuries). Employers shall report to

the Commission all injuries resulting in the loss of more than three scheduled workdays. Filing this form does not affect liability under the

Workers’ Compensation Act and is not incriminatory in any sense. This information is confidential. IC45 8/12


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