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The Illinois Form 45, known as the Employer's First Report of Injury, plays a crucial role in the workers' compensation process. Employers must complete this form when an employee experiences a work-related injury or illness that results in lost workdays. Essential information is required on the form, including the employer's details, the employee's information, and specifics about the incident itself. Key sections cover the nature of the accident, the employee's job title, and the type of injury sustained. Employers must also indicate whether the accident occurred on their premises and provide details about any medical treatment received. The form must be submitted to the Illinois Workers' Compensation Commission, ensuring that all relevant parties are informed and that proper records are maintained. While it is a legal requirement to file this report for significant injuries, submitting the form does not imply liability under the Workers' Compensation Act. The information contained in the form is confidential, safeguarding the privacy of both the employer and employee.
Example - Illinois 45 Form
ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY
Please type or print.
Employer's FEIN
Employer's name
Date of report |
Case or File # |
Is this a lost workday case? |
Yes / No
Doing business as
Employer's mailing address
Nature of business or service
SIC code
Name of workers' compensation carrier/admin. |
Policy/Contract # |
Yes / No
Employee's full name |
Social Security # |
Birthdate |
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Employee's mailing address
Employee's
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# Dependents |
Employee's average weekly wage |
Male / Female |
Married / Single |
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Job title or occupation |
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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? |
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Was the employee hospitalized overnight as an inpatient? |
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Yes / No |
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Yes |
/ No |
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Report prepared by |
Signature |
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Title and telephone # |
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Please send this form to the ILLINOIS WORKERS' COMPENSATION COMMISSION |
701 S. SECOND STREET SPRINGFIELD, IL 62704. IC45 12/04 |
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By law, employers must keep accurate records of all
Document Breakdown
| Fact Name | Details |
|---|---|
| Purpose | The Illinois Form 45 serves as the Employer's First Report of Injury, documenting work-related injuries and illnesses. |
| Governing Law | This form is governed by the Illinois Workers' Compensation Act, which mandates reporting certain work-related injuries. |
| Submission Requirements | Employers must submit the form to the Illinois Workers' Compensation Commission within specific timeframes, especially for injuries resulting in lost workdays. |
| Confidentiality | Information provided on this form is confidential and cannot be used against the employer in legal contexts. |
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