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 Illinois Unemployment Compensation #
Date of report
Case or File #
Employer's name
Is this a lost workday case?
___ Yes
___ No
Doing business under the name of
Mailing address
City
State
Zip code
Employer location, if different from mailing address
Nature of business or service
SIC code
Name of workers' compensation carrier/admin.
Policy/Contract #
Self-insured?
County of accident site
___ Yes
___ No
Employee's name (last, middle, first)
Social Security #
Employee's street address
City
State
Zip code
Birthdate
# Dependents
___ Male
___ Female
___ Married ___ Single
Date & time of accident
Employee's average weekly wage
Last day employee worked
Job title or occupation
Address of accident
City
State
Zip code
Did the employee die as a result of the accident?
If yes, give the date of death
___ Yes
___ No
Did the accident occur on the employer's premises?
This accident resulted in
___ Yes
___ No
___ Occupational injury
___ Occupational disease
Nature of the injury
Part of body affected (be specific)
What task was the employee performing when the accident occurred?
Object or substance responsible for accident, if any (source)
How did accident occur?
What hazardous conditions, if any, contributed to the accident?
What unsafe act, if any, contributed to the accident?
Have medical services been rendered to the employee?
Has the employee been hospitalized?
___ Yes
___ No
___ Yes
___ No
Name and address of physician
City
State
Zip code
Name and address of hospital
City
State
Zip code
Report prepared by
Signature
Title and telephone #
Please send this form to the ILLINOIS INDUSTRIAL COMMISSION 701 S. SECOND STREET SPRINGFIELD, IL 62704 .
IC45 1/00
By law, employers shall maintain 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