ILLINOIS FORM 85: EMPLOYER'S SUPPLEMENTARY REPORT OF INJURY Employer's FEIN Date of report Case or File # Please type or print. This report is Supplementary Employer's name Doing business as Employer's full mailing address Employer's email address Nature of business or service SIC code Name of workers' compensation carrier/admin. Policy/Contract # Self-insured? Yes Insurer's mailing address City State Zip code Employee's full name Birthdate Employee's full mailing address Employee's email address Date of injury/diagnosis Date of first payment Employee's average weekly wage # Dependents Period of disability If the employee died as a result of the accident, give the date of death. BENEFIT INFORMATION Please provide a comprehensive history of payments. Payment Type (TTD, medical, etc.) Weekly Payment Number of Weeks Benefit Paid From Through Total Payments Grand total Was this case closed by the Industrial Commission? If so, how was the case resolved? $ Yes Report prepared by Signature Settlement contract Title, telephone #, and email address Please send this form to: ILLINOIS WORKERS' COMPENSATION COMMISSION 4500 S. SIXTH ST. FRONTAGE ROAD SPRINGFIELD, IL 62703-5118 In addition to the Employer's First Report of Injury (IC45), employers shall file this report when 1) benefits begin or are stopped; 2) there is a change in the employee's status; 3) final compensation is made. This information is confidential. IC85 8/12 American LegalNet, Inc. www.FormsWorkFlow.com