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
Doing business as
Employer's mailing address
Nature of business or service
Name of workers' compensation carrier/admin.
Self-insured? Yes / No Zip code
Insurer's mailing address
Employee's full name
Social Security #
Employee's street address
Date of injury/diagnosis
Date of first payment
Employee's average weekly wage
Period of disability
If the employee died as a result of the accident, give the date of death.
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