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ILLINOIS FORM 85: EMPLOYER'S SUPPLEMENTARY REPORT OF INJURY
Employer's FEIN Date of report Case or File #

Please type or print.
This report is Supplementary / Final

Employer's name

Doing business as

Employer's mailing address

City

State

Zip code

Nature of business or service

SIC code

Name of workers' compensation carrier/admin.

Policy/Contract #

Self-insured? Yes / No Zip code

Insurer's mailing address

City

State

Employee's full name

Social Security #

Birthdate

Employee's street address

City

State

Zip code

Date of injury/diagnosis

Date of first payment

Employee's average weekly wage

# Dependents

Period of disability

If the employee died as a result of the accident, give the date of death.

BENEFIT INFORMATION
Please provide a comprehensive history of payments.
Payment Type (TTD, medical, etc.) Weekly Payment Number of Weeks Benefit Paid From Through Total Payments

Grand total Was this case closed by the Industrial Commission? Yes / No Signature If so, how was the case resolved? Settlement contract / Arbitration decision / Title and telephone #

$ Commission decision

Report prepared by

Please send this form to: ILLINOIS WORKERS' COMPENSATION COMMISSION 4500 S. SIXTH ST. FRONTAGE ROAD SPRINGFIELD, IL 62703-5118 In addition to the Employer's First Report of Injury (IC45), employers shall file this report when 1) benefits begin or are stopped; 2) there is a change in the employee's status; 3) final compensation is made. This information is confidential. IC85 6/09