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ILLINOIS WORKERS' COMPENSATION COMMISSION
Accident Reporting System Electronic Data Interchange Information Packet
Last Revised May 2009

ILLINOIS WORKERS' COMPENSATION COMMISSION 100 W. RANDOLPH ST. #8-200 CHICAGO, IL 60601 BENNIE HORTON, JR., EDI COORDINATOR 312/814-6179 [email protected]

ELECTRONIC DATA INTERCHANGE

We welcome your participation in the electronic exchange of accident report data. We have worked with the International Association of Industrial Accident Boards and Commissions (IAIABC) to develop a layout for accident reports that is used by many carriers and self-insurers. Currently, we can only accept the First Report of Injury electronically. Our standard format is attached. It shows the IAIABC groupings as well as their elements and sources. We accept transmissions through two vendors: GXS/IBMIS (877/326-6426, option 3, then option 1) and Peak Performance (866/448-1776, press option 1). The Commission does not assume any transmission charges. Once we receive a transmission, we will send you a confirmation. If we find errors, we will send you a printout, listing the fields that are in error. If you have an error, please resend your corrected record with a "02" in the 4th and 5th positions, which is the field, "Transaction Set Purpose Code." We have made every effort to make this process run smoothly, but we do invite your suggestions for improvement. If you have any questions, or are ready to start transmitting data electronically, please call Bennie Horton, Jr., at 312/814-6179. We look forward to working with you. Illinois Workers' Compensation Commission

ACCIDENT REPORTING PROVISIONS
UNDER THE ILLINOIS WORKERS' COMPENSATION ACT

820 ILCS 305/6
Section 6(b). Every employer subject to this Act shall maintain accurate records of work-related deaths, injuries and illness other than minor injuries requiring only first aid treatment and which do not involve medical treatment, loss of consciousness, restriction of work or motion, or transfer to another job and file with the Commission, in writing, a report of all accidental deaths, injuries and illnesses arising out of and in the course of the employment resulting in the loss of more than 3 scheduled work days. In the case of death such report shall be made no later than 2 working days following the accidental death. In all other cases such report shall be made between the 15th and 25th of each month unless required to be made sooner by rule of the Commission. In case the injury results in permanent disability, a further report shall be made as soon as it is determined that such permanent disability has resulted or will result from the injury. All reports shall state the date of the injury, including the time of day or night, the nature of the employer's business, the name, address, age, sex, conjugal condition of the injured person, the specific occupation of the injured person, the direct cause of the injury and the nature of the accident, the character of the injury, the length of disability, and in case of death the length of disability before death, the wages of the injured person, whether compensation has been paid to the injured person, or to his or her legal representative or his heirs or next of kin, the amount of compensation paid, the amount paid for physicians', surgeons' and hospital bills, and by whom paid, and the amount paid for funeral or burial expenses if known. The reports shall be made on forms and in the manner as prescribed by the Commission and shall contain such further information as the Commission shall deem necessary and require. The making of these reports releases the employer from making such reports to any other officer of the State and shall satisfy the reporting provisions as contained in the "Health and Safety Act" and "An Act in relation to safety inspections and education in industrial and commercial establishments and to repeal an Act therein named", approved July 18, 1955, as now or hereafter amended. The reports filed with the Commission pursuant to this Section shall be made available by the Commission to the Director of Labor or his representatives and to all other departments of the State of Illinois, which shall require such information for the proper discharge of their official duties. Failure to file with the Commission any of the reports required in this Section is a petty offense. Except as provided in this paragraph, all reports filed hereunder shall be confidential and any person having access to such records filed with the Industrial Commission as herein required, who shall release any information therein contained including the names or otherwise identify any persons sustaining injuries or disabilities, or give access to such information to any unauthorized person, shall be subject to discipline or discharge, and in addition shall be guilty of a Class B misdemeanor. The Commission shall compile and distribute to interested persons aggregate statistics, taken from the reports filed hereunder. The aggregate statistics shall not give the names or otherwise identify persons sustaining injuries or disabilities or the employer of any injured or disabled person. (Source: P.A. 84-981) Note: Effective January 1, 2005, the Illinois Industrial Commission became the Illinois Workers' Compensation Commission. The law states that any reference to the Industrial Commission should be considered a reference to the Workers' Compensation Commission.

IAIABC FLAT FILE FORMAT IAIABC EDT STANDARD POSITION GROUPING IAIABC ELEMENT IWCC FORMAT BEG END ELEMENTS SOURCE RULES Transaction Transaction Set ID ANSI 143 REQ 3 A/N 1 3 Transaction Transaction Set Purpose Code ANSI 353 REQ 2 A/N 4 5 Transaction Transaction Set Date IAIABC OPT DATE 6 13 Claimant Social Security Number DCI FLD 10 REQ 9 A/N 659 667 Accident Date of Injury IAIABC REQ DATE 463 470 Accident Agency Claim Number IAIABC OPT 25 A/N 16 40 Accident Time of Injury IAIABC REQ HHMM 471 474 Insured Employer Code FEIN IAIABC REQ 9 A/N 230 238 Insured Employer Name IAIABC REQ 30 A/N 269 298 Insured Employer Address Line 1 IAIABC OPT 30 A/N 299 328 Insured Employer Address Line 2 IAIABC OPT 30 A/N 329 358 Insured Employer City IAIABC OPT 15 A/N 359 373 Insured Employer State IAIABC OPT 2 A/N 374 375 Insured Employer Postal Code Zip IAIABC OPT 5 A/N 376 380 Insured Employer Postal Code Plus 4 IAIABC OPT 4 A/N 381 384 Claim Admin. Claim Admin. Code FEIN IAIABC REQ 9 A/N 41 49 Policy Policy Number DCI FLD 10 OPT 30 A/N 417 446 Policy Claimant Last Name IAIABC REQ 30 A/N 668 697 Policy Claimant First Name IAIABC REQ 15 A/N 698 712 Policy Claimant Middle Initial IAIABC OPT 1 A/N 713 713 Policy Claimant Address Line 1 IAIABC REQ 30 A/N 714 743 Policy Claimant Address Line 2 IAIABC OPT 30 A/N 744 773 Policy Claimant City IAIABC REQ 15 A/N 774 788 Policy Claimant State IAIABC REQ 2 A/N 789 790

CONVERSION RULES INPUT OUTPUT '148' NA ' 00 ' CCYYMMDD XXXXXXXXX CCYYMMDD 'IC45' '1' 'N' , else 'R' MM-DD-CC-YY XXX-XX-X-XXX MM-DD-CC-YY LEFT 10 POS. Same XXXXXXXXX XX-XXXXXXX Same Same Same Same Same Same Same XXXXXXXXX XX-XXXXXXX Left 18 CHAR. Same Left 14 CHAR. Same Same Same Same Same

REQ = REQUIRED

OPT = OPTIONAL

IAIABC FLAT FILE FORMAT IAIABC EDT STANDARD POSITION FORMAT BEG 5 A/N 4 A/N 1 A/N DATE 1 A/N 2N DATE S9.2 DATE DATE DATE 1 A/N 6 A/N 4 A/N 2 A/N 2 A/N 2 A/N 150A/N 5 A/N 4 A/N 791 796 819 810 818 820 830 882 896 643 906 484 386 840 487 485 489 491 475 480 CONVERSION RULES INPUT OUTPUT Same Same 'M' , else 'S' MM-DD-CC-YY 'F' , else 'M' Same MM-DD-CC-YY Same MM-DD-CC-YY MM-DD-CC-YY MM-DD-CC-YY Same Left 4 Digits Same Same Same Same Left 10 Char. Blanks Same Same

GROUPING Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy Policy

IAIABC ELEMENTS Claimant Postal Code Zip Claimant Postal Code + 4 Marital Status Code - S,M Date of Birth Gender Code - F,M,or U Number of Dependents Date of Death Wage Date Last Day Worked Date Reported to Employer Date of Return to Work Employer's Premises Indicator Sic Code Class Code Part of Body Injured Code Nature of Injury Code Cause of Injury Code Accident Description / Cause Postal Code of Injury Site Zip Postal Code of Injury Site + 4

ELEMENT SOURCE IAIABC IAIABC ANSI 1067 IAIABC ANSI 1068 IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC DCI FLD 23 DCI FLD 24 DCI FLD 25 DCI FLD 26 IAIABC IAIABC IAIABC

IWCC RULES REQ OPT REQ OPT REQ OPT REQ REQ OPT OPT OPT OPT REQ REQ REQ REQ REQ REQ OPT OPT

END 795 799 819 817 818 821 837 892 903 650 913 484 391 843 488 486 490 640 479 483

'M' CCYYMMDD 'F' CCYYMMDD CCYYMMDD CCYYMMDD CCYYMMDD

NA

REQ = REQUIRED

OPT = OPTIONAL

GROUPING Policy Initial Treatment

IAIABC ELEMENTS

IAIABC FLAT FILE FORMAT IAIABC EDT STANDARD POSITION ELEMENT IWCC FORMAT BEG SOURCE RULES IAIABC OPT 2 A/N 641

END 642 NA NA NA

CONVERSION RULES INPUT OUTPUT 'N' Blanks 'N' Blanks NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Jurisdiction Jurisdiction Jurisdiction Jurisdiction Jurisdiction Jurisdiction Jurisdiction Employment Employment Employment Employment Employment Employment Employment Employment Employment Employment Employment Employment Employment Employment Employment Employment Employment Employment Employment

Jurisdiction Insured Name Self Insured Indicator Claim Admin. Name Policy Effective Claimant Phone Date Disability Began Employment Status Code Wage Period Full Wages Paid for Date of Injury Date Reported to Claims Admin. Insured Report Number Occupation Description Independent Adjuster Code Policy Expiration Number of Days Worked Salary Continued Indicator Insured Location Number Date of Hire Independent Adjuster Name Claim Admin. Address Line 1 Claim Admin. Address Line 2 Claim Admin. Address City Claim Admin. Address State Claim Admin. Address Postal Code Claim Admin. Claim Number

IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC / DISAB IAIABC DCI FLD 9 IAIABC IAIABC IAIABC IAIABC IAIABC / ANSI IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC

OPT OPT REQ OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT OPT

2 A/N 30 A/N 1 A/N 30 A/N DATE 10 A/N DATE 2 A/N 2 A/N 1 A/N DATE 10 A/N 30 A/N 9 A/N DATE 1N 1 A/N 15 A/N DATE 30 A/N 30 A/N 30 A/N 15 A/N 2 A/N 9 A/N 25 A/N

14 239 385 50 447 800 822 838 893 904 651 392 844 80 455 895 905 402 874 89 119 149 179 194 196 205

15 268 385 79 454 809 829 839 894 904 658 401 873 88 462 895 905 416 881 118 148 178 193 195 204 229

REQ = REQUIRED

OPT = OPTIONAL