Free Adobe PDF - Illinois

File Size: 405.7 kB
Pages: 1
Date: June 24, 2009
File Format: PDF
State: Illinois
Category: Workers Compensation
Word Count: 300 Words, 1,926 Characters
Page Size: Letter (8 1/2" x 11")

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Employer's FEIN Date of report Case or File #

Please type or print.
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 #


Employee's mailing address

Employee's e-mail address

# Dependents Male / Female Married / Single

Employee's average weekly wage

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 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.