Fill a Valid Illinois First Report 45 Form

The Illinois First Report 45 form is a document that employers must complete to report any work-related injuries or illnesses involving their employees. This form captures essential details about the incident, including the nature of the injury, employee information, and specifics about the accident. To ensure compliance and maintain accurate records, fill out the form by clicking the button below.

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Fill a Valid Illinois First Report 45 Form

Table of Contents

The Illinois First Report 45 form is a crucial document that employers must complete when a work-related injury occurs. Designed to capture essential information, this form helps ensure that both employees and employers navigate the complexities of workers' compensation effectively. Key details required include the employer's information, such as the Federal Employer Identification Number (FEIN), business name, and mailing address. It also asks for specifics about the injured employee, including their name, birthdate, and job title. Understanding whether the incident resulted in lost workdays is vital, as this can influence the reporting process. The form delves into the circumstances surrounding the accident, requesting descriptions of what the employee was doing at the time, how the injury occurred, and the nature of the injury itself. Additional inquiries cover medical treatment received, including whether the employee was treated in an emergency room or hospitalized. By gathering this information, the form serves not only as a report to the Illinois Workers' Compensation Commission but also as a means for employers to maintain compliance with legal requirements. Remember, filing this form is a step toward protecting both the rights of the injured employee and the interests of the employer.

Example - Illinois First Report 45 Form

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

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

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

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

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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Document Breakdown

Fact Name	Description
Purpose	The Illinois First Report 45 form is used by employers to report work-related injuries or illnesses to the Illinois Workers' Compensation Commission.
Governing Law	This form is governed by the Illinois Workers' Compensation Act, which mandates reporting of certain injuries.
Lost Workday Cases	Employers must indicate if the reported case involves lost workdays, which triggers specific reporting requirements.
Confidentiality	The information provided in the form is confidential and is protected under Illinois law.
Submission Requirements	Employers are required to submit this form to the Illinois Workers' Compensation Commission within a specified timeframe following an incident.
Record-Keeping Obligation	Employers must maintain accurate records of all work-related injuries and illnesses, as mandated by law.
Non-Incriminatory	Filing the First Report 45 form does not affect the employer's liability under the Workers' Compensation Act and is not considered an admission of guilt.

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