Workers Compensation Employees Notice Of Injury
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1
2ILLINOIS
Division of Risk Management
CMS
DEPARTMENT OF CENTRAL
Claims Section
MANAGEMENT SERVICES
WORKERS’ COMPENSATION EMPLOYEE’S NOTICE OF INJURY (COMPLETE ALL ITEMS)
(last)
(first)
EMPLOYEE’S NAME
(no.)
(street)
EMPLOYEE’S ADDRESS
(city)
(state)
(zip)
TELEPHONE Home _________________________
Work _________________________
SOCIAL
DATE OF
(mo)
(day)
(year)
o Female
o Male
SECURITY NO.
BIRTH
SEX:
NUMBER OF DEPENDENT CHILDREN
o Married
o Single
o Widow(er)
o Divorced
MARITAL STATUS:
UNDER 18 AT DATE OF INJURY __________
(mo)
(day)
(year)
A.M.
DATE OF INJURY OR ILLNESS
TIME
P.M.
LAST DAY WORKED
NAME OF AGENCY
ADDRESS OF AGENCY
WORK COUNTY
REPORTED TO
NAME OF
DATE & TIME
o Yes
o No
SUPERVISOR
SUPERVISOR
REPORTED
a.m. p.m. (mo)
(day)
(year)
IF NOT REPORTED ON
DATE OF INCIDENT, EXPLAIN
HAVE YOU SOUGHT
NAME, ADDRESS
o Yes
o No
MEDICAL ATTENTION
PHONE NO. OF DOCTOR
ANY SICK, VACATION OR PERSONAL
o Yes
o No
DAYS USED FOR THIS INJURY?
NUMBER AND TYPE
HAS ANY INSURANCE COMPANY PAID FOR
NAME AND
o Yes
o No
TREATMENT AS A RESULT OF THIS INJURY
POLICY NO.
WHAT DUTY WERE YOU PERFORMING
AT TIME OF INJURY? (BE SPECIFIC)
PLACE WHERE INJURY
OCCURRED (BE SPECIFIC)
DETAIL HOW INJURY OCCURRED
(USE REVERSE SIDE IF NECESSARY)
o Yes
o No
DID A NEGLIGENT THIRD PARTY CAUSE OR CONTRIBUTE TO ACCIDENT?
IF YES, EXPLAIN AND PROVIDE, ADDRESS, AND PHONE # OF NEGLIGENT PARTY:
(USE REVERSE SIDE IF NECESSARY)
DESCRIBE INJURY (INDICATE PART(S) OF BODY AFFECTED)
IF YES, NAME(S)
ANY WITNESS(S)
o Yes
o No
TO INJURY
HAVE YOU SUBMITTED ANY PREVIOUS CLAIMS FOR INJURY / ILLNESS?
o Yes
o No
(IF YES, IDENTIFY EACH ON REVERSE SIDE)
DATE THIS FORM
SIGNATURE OF
COMPLETED
________________________________
INJURED EMPLOYEE ________________________________________________________
(mo)
(day)
(year)
IF INJURED EMPLOYEE UNABLE TO SIGN ABOVE,
SIGNATURE OF INDIVIDUAL COMPLETING THIS FORM
Reverse side must be completed if applicable before submission to CMS
CMS-900-1 IL 401-0012 (Rev. 8/04)
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