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? Yes Employee's full name     Employee's mailing address / Female No Employee's e-mail address # Dependents Male /     Birthdate Married / Employee's average weekly wage Single Job title or occupation Time employee began work Date hired 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? Yes / No 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? Yes / Was the employee hospitalized overnight as an inpatient? No Report prepared by Yes Signature / No Title and telephone # Please send this form to the ILLINOIS WORKERS' COMPENSATION COMMISSION 4500 S. SIXTH ST. FRONTAGE RD. SPRINGFIELD, IL 62703-5118 IC45 11/11 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. American LegalNet, Inc. www.FormsWorkFlow.com