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Get Illinois Form 45 2011

ILLINOIS FORM 45 EMPLOYER S FIRST REPORT OF INJURY Employer s FEIN Date of report Please type or print. Case or File Is this a lost workday case Yes Employer s name / No Doing business as Employer s mailing address Nature of business or service SIC code Name of workers compensation carrier/admin. Policy/Contract Self-insured Employee s full name Social Security Employee s e-mail address Dependents Male Birthdate Female Married Employee s average weekly wage Single Job title or occupation Date hired Time employee began work Date and time of accident Last day employee worked AM PM 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 Report prepared by Signature Please send this form to the ILLINOIS WORKERS COMPENSATION COMMISSION Title and telephone 701 S* SECOND STREET SPRINGFIELD IL 62704. 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. 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 Report prepared by Signature Please send this form to the ILLINOIS WORKERS COMPENSATION COMMISSION Title and telephone 701 S* SECOND STREET SPRINGFIELD IL 62704. By law employers must keep accurate records of all work-related injuries and illness except for certain minor injuries. 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. 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. 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 Report prepared by Signature Please send this form to the ILLINOIS WORKERS COMPENSATION COMMISSION Title and telephone 701 S* SECOND STREET SPRINGFIELD IL 62704. 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. .

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