ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY Please type or print. Employer's FEIN Is this a lost workday case? Date of report Case or File # Yes 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? Yes No Employee's full name Birthdate Employee's mailing address Employee's e-mail address Gender Marital status Male # Dependents Single Job title or occupation Time employee began work Employee's average weekly wage Date hired Date and time of accident Last day employee worked A.M. 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 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? Yes Yes Report prepared by Signature Title and telephone # Email address Please send this form to: ILLINOIS WORKERS' COMPENSATION COMMISSION 4500 S. SIXTH ST. FRONTAGE RD SPRINGFIELD, IL 62703 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 way. This information is confidential. IC45 8/12 American LegalNet, Inc. www.FormsWorkFlow.com