Illinois form 45: employer's first report of injury

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ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY Please type or print. 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 Yüklə 29.61 Kb. Dostları ilə paylaş: