2004 Il Form PDF Details

Every year, there are new fashion trends that become popular. One trend that has been resurfacing recently is 2004 il Form. This style was popular back in the early 2000s and is now making a comeback. If you're wondering what this style is all about, read on to learn more.

Form Name2004 Il Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesincriminatory, worksite, 2004 form, 2004 h8 form

Form Preview Example


Please type or print.


Employer's FEIN


Date of report


Case or File #

Is this a lost workday case?








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 #










Employee's full name












Employee's mailing address




Employee's e-mail address









Marital status


# Dependents

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?


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?





Report prepared by



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

2. Once your current task is complete, take the next step – fill out all of these fields - If the employee died as a result, Address of accident, What was the employee doing when, How did the accident occur, Did the accident occur on the, Yes No, What was the injury or illness, What object or substance if any, Name and address of, If treatment was given away from, Was the employee treated in an, Was the employee hospitalized, Yes No Report prepared by, Signature, and Yes No Title and telephone with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

2004 il completion process described (step 2)

Always be very careful when completing Did the accident occur on the and How did the accident occur, as this is where most people make a few mistakes.

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