Illinois Employer's Supplementary Report of Injury
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ILLINOIS FORM 85: EMPLOYER'S SUPPLEMENTARY REPORT OF INJURY
Employer's FEIN

Date of report

Please type or print.

Case or File #

This report is
Supplementary / Final

Employer's name

Doing business as

Employer's full mailing address

Employer's email address

Nature of business or service

SIC code

Name of workers' compensation carrier/admin.

Policy/Contract #

Self-insured?

Insurer's mailing address

City

State

Yes

Employee's full name

No
Zip code

Birthdate

Employee's full mailing address

Date of injury/diagnosis

/

Employee's email address

Date of first payment

Period of disability

Employee's average weekly wage

# Dependents

If the employee died as a result of the accident, give the date of death.

BENEFIT INFORMATION
Please provide a comprehensive history of payments.
Payment Type

Weekly

Number of

(TTD, medical, etc.)

Payment

Weeks

Benefit Paid
From

Total

Through

Payments

Grand total
Was this case closed by the Industrial Commission?
Yes /

No

Report