Illinois First Report Form 45 PDF Details

In the state of Illinois, the meticulous documentation and reporting of workplace injuries are not just good practices but legal requirements. This responsibility is encapsulated in the Illinois First Report 45 form, a document that employers must fill out following a work-related injury. The form is comprehensive, asking for details ranging from the employer's Federal Employer Identification Number (FEIN) to the specifics of the injury itself, including the nature, location, and how it occurred. It also delves into the employee's personal information, such as their birthdate, marital status, and number of dependents, designed to ensure a thorough understanding of the impact of the injury. Crucially, the form queries about whether the incident resulted in lost workdays, a key factor in determining the seriousness of an injury. Furthermore, it requires information about the workers' compensation insurance, highlighting its role as a pivotal component of the process. Despite its detailed nature, completing this form does not imply liability under the Workers’ Compensation Act, nor is it incriminatory. However, it is essential in facilitating the effective management of workplace injuries, underscoring the importance of accuracy and promptness in its submission to the Illinois Workers' Compensation Commission. This document thus serves as a vital link between employers, employees, and regulatory bodies, ensuring that the aftermath of work-related injuries is handled with the requisite care and procedural fidelity.

QuestionAnswer
Form NameIllinois First Report Form 45
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesillinois first report of injury form, illinois first report of injury form fillable, osha form 45, illinois form 45 fillable

Form Preview Example

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?

 

 

 

 

 

 

 

 

Yes

 

No

 

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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Complete the Male Female Job title or occupation, Married Single, Date hired, Time employee began work, Date and time of accident, Last day employee worked, If the employee died as a result, Did the accident occur on the, Yes No, Address of accident, What was the employee doing when, How did the accident occur, What was the injury or illness, What object or substance if any, and Name and address of section using the particulars requested by the program.

illinois form 45 pdf Male Female Job title or occupation, Married Single, Date hired, Time employee began work, Date and time of accident, Last day employee worked, If the employee died as a result, Did the accident occur on the, Yes No, Address of accident, What was the employee doing when, How did the accident occur, What was the injury or illness, What object or substance if any, and Name and address of blanks to fill

Note the vital information in Was the employee treated in an, Was the employee hospitalized, Yes No Report prepared by, Signature, Yes No Title and telephone, Email address, and Please send this form to ILLINOIS segment.

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