Illinois Employer's First Report of Injury
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ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY
Employer's FEIN

Date of report

Please type or print.

Case or File #

Is this a lost workday case?
Yes

Employer's name

No

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

Male
Female
Job title or occupation

Time employee began work

Married

# Dependents

Employee's average weekly wage

Single
Date hired

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