2004 Il Form PDF Details

The 2004 IL Form, officially known as Illinois Form 45: Employer's First Report of Injury, serves as a critical first step for employers documenting workplace incidents leading to employee injuries. Employers are required to fill out this form thoroughly, providing details such as the Federal Employer Identification Number (FEIN), case or file number, and determining if the incident resulted in lost workdays. It also collects comprehensive employer details, including names, addresses, and the nature of the business, alongside information on the workers' compensation carrier. The form extends to gather required personal and employment-related data from the injured employee, including full name, address, email, gender, marital status, dependents, average weekly wage, and details surrounding the injury such as date, time, location, and nature of the action being performed when the accident occurred. Additionally, it asks for descriptions of the injury or illness, parts of the body affected, and any objects or substances that directly caused harm. Critical to completing the form are the details of medical treatment, specifying whether it was treated at the worksite, in an emergency room, or led to hospitalization. Completed by the employer, this document plays a crucial part in the Illinois Workers' Compensation process, ensuring accurate record keeping for work-related injuries or illnesses that necessitate more than three days off work. It emphasizes the importance of prompt and precise reporting in the compensation claims process, fulfilling both state legal requirements and facilitating a smoother handling of workers' compensation matters. The form, once filled, is to be sent to the Illinois Workers' Compensation Commission, ensuring confidentiality and non-incriminatory treatment of provided information as mandated by law.

QuestionAnswer
Form Name2004 Il Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesincriminatory, worksite, 2004 form, 2004 h8 form

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ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY

Please type or print.

 

Employer's FEIN

 

Date of report

 

Case or File #

Is this a lost workday case?

 

 

 

 

 

Yes

No

Employer's name

 

 

 

Doing business as

 

 

 

 

 

 

 

Employer's mailing address

 

 

 

Employer’s email address

 

 

 

 

 

 

Nature of business or service

 

 

 

SIC code

 

 

 

 

 

 

 

Name of workers' compensation carrier/admin.

 

Policy/Contract #

Self-insured?

 

 

 

 

 

 

Yes

No

Employee's full name

 

 

 

 

Birthdate

 

 

 

 

 

 

Employee's mailing address

 

 

 

Employee's e-mail address

 

 

 

 

 

 

Gender

 

Marital status

 

# Dependents

Employee's average weekly wage

Male

Female

Married

Single

 

 

 

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?

YesNo

Address of accident

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?

Was the employee hospitalized overnight as an inpatient?

Yes

No

Yes

No

Report prepared by

 

Signature

Title and telephone #

 

Email address

 

 

 

 

 

 

Please send this form to: ILLINOIS WORKERS' COMPENSATION COMMISSION 4500 S. SIXTH ST. FRONTAGE RD SPRINGFIELD, IL 62703 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 way. This information is confidential. IC45 8/12

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Step # 1 in completing 2004 il

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2004 il completion process described (step 2)

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