Get 85illions Form

Filling out the 85illions Form online requires careful attention to detail. This guide will provide clear, step-by-step instructions to help you accurately complete the form and ensure compliance with reporting requirements.

Follow the steps to complete your 85illions Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the employer's Federal Employer Identification Number (FEIN) in the designated field. This is critical for identifying the employer associated with the report.
3. Provide the date of the report. Ensure that you are using the correct format to avoid any miscommunication.
4. Fill in the case or file number to reference the particular incident related to the injury.
5. Indicate whether the report is supplementary or final. Check the appropriate box based on the situation.
6. Complete the employer's name and doing business as information. This helps clarify the entity responsible.
7. Input the full mailing address for the employer, including the email address for communication purposes.
8. Describe the nature of the business or service provided by the employer along with the Standard Industrial Classification (SIC) code.
9. Record the name of the workers' compensation carrier or administrator along with the policy or contract number.
10. Indicate if the employer is self-insured by checking 'Yes' or 'No'. If applicable, fill in the insurer's mailing address followed by the city, state, and zip code.
11. Input the employee's full name and mailing address, ensuring all details are accurate.
12. Provide the employee's birthdate and the date of the injury or diagnosis.
13. Enter the date of the first payment and the employee's average weekly wage for record-keeping.
14. Indicate the number of dependents and, if relevant, provide the date of death for the employee as a result of the accident.
15. Under benefit information, provide a comprehensive history of payments, including payment type, number of weeks, total payments made, and the grand total.
16. Specify whether the case was closed by the Industrial Commission and indicate how the case was resolved, if applicable.
17. Include the name and contact information for the individual preparing the report.
18. Once completed, save changes, download the form, print, or share it as necessary.

Complete your 85illions Form online today to ensure timely and accurate reporting.