Form 45 - Employer'S First Report Of Injury
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1ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY
Please type or print.
Employer's FEIN
Date of report
Case or File #
Is this a lost workday case?
Yes
/
No
Employer's name
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
/
No
Employee's full name
Social Security #
Birthdate
Employee's mailing address
Employee's e-mail address
# Dependents
Employee's average weekly wage
Male
/
Female
Married
/
Single
Job title or occupation
Date hired
Time employee began work
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?
Was the employee hospitalized overnight as an inpatient?
Yes
/
No
Yes
/
No
Report prepared by
Signature
Title and telephone #
Please send this form to the ILLINOIS INDUSTRIAL COMMISSION 701 S. SECOND STREET SPRINGFIELD, IL 62704.
IC45 9/03
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.
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Parent category: Business