ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY
Employer's FEIN Date of report Case or File #
Please type or print.
Is this a lost workday case? Yes / No
Doing business as
Employer's mailing address
Nature of business or service
Name of workers' compensation carrier/admin.
Self-insured? Yes / No
Employee's full name
Social Security #
Employee's mailing address
Employee's e-mail address
# Dependents Male / Female Married / Single
Employee's average weekly wage
Job title or occupation
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 Address of accident / No
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? Yes / No Signature
Was the employee hospitalized overnight as an inpatient? Yes / No Title and telephone #
Report prepared by
Please send this form to the ILLINOIS WORKERS' COMPENSATION COMMISSION 4500 S. SIXTH ST. FRONTAGE RD. SPRINGFIELD, IL 62703-5118 IC45 6/09 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.