Illinois Form 45 Employer's First Report of Injury

Submit the completed Illinois Form 45 to the Illinois Workers' Compensation Commission at the following address: 4500 S. Sixth St. Frontage Road, Springfield, IL 62703-5118. You can also send it via fax to the designated number provided by the commission. Ensure you keep copies for your records and confirm receipt by the commission.

Important dates for Illinois Form 45 include submission deadlines associated with particular injury reports. Ensure timely completion to avoid penalties. Check local guidelines for specific deadlines relevant to your submissions.

The Illinois Form 45 serves as the primary document for employers to report workplace injuries to the Workers' Compensation Commission. It gathers vital information about the incident, employee, and nature of the injury. This form is critical in ensuring compliance with state regulations and facilitating workers' compensation claims.

• 1. Employer's FEIN: Federal Employer Identification Number required for the employer.
• 2. Date of Report: The date when the report is completed.
• 3. Case of File #: The case reference number assigned to the report.
• 4. Employer's Name: Full name of the employer.
• 5. Is this a lost workday case?: Indicate if the injury resulted in lost workdays.
• 6. Doing business as: The trade name of the business, if different from the employer's name.
• 7. Employer's mailing address: Physical mailing address of the employer.
• 8. Nature of business or service: Description of what the business does.
• 9. Name of Worker's Compensation carrier/admin: The name of the insurance carrier or third-party administrator.
• 10. Policy / contract #: The policy or contract number related to worker's compensation.
• 11. Employee's full name: Full name of the employee involved in the incident.
• 12. Home Phone #: Contact number for the employee.
• 13. SIC code: Standard Industrial Classification code for the employer's industry.
• 14. Self-insured: Indication if the employer is self-insured.
• 15. Social security #: Social security number of the employee.
• 16. Employee's mailing address: Physical mailing address of the employee.
• 17. # Dependents: Number of dependents the employee has.
• 18. Job title or occupation: Official job title or occupation of the employee.
• 19. Time employee began work: Start time of the employee's shift on the day of the incident.
• 20. Date and time of accident: When the accident occurred.
• 21. If the employee died as a result of the accident, give date of death: Date of death if applicable.
• 22. Department: Department where the employee worked.
• 23. Birthdate: Employee's date of birth.
• 24. Employee's email address: Email address of the employee.
• 25. Employee's average weekly wage: Employee's average earnings per week.
• 26. Date hired: Date when the employee was hired.
• 27. Last day employee worked: Last working day before the incident.
• 28. Did the accident occur on the employer's premis: Indicate if the accident happened on company property.
• 29. Address of accident: Location where the accident took place.
• 30. What was the employee doing when the accident occurred?: Description of the employee's activity during the incident.
• 31. How did the accident occur?: Explanation of the circumstances leading to the accident.
• 32. What was the injury or illness? List the body affected and explain how it was affected: Detailed description of the injury or illness.
• 33. What object or substance, if any, directly harmed the employee?: Identify any object or substance involved in the injury.
• 34. Name and address of physician/healthcare professional: Contact information for the healthcare provider.
• 35. If treatment was given away from the worksite, list the name and address of place it was given: Information on treatment location outside of the workplace.
• 36. Was the employee treated in an emergency room?: Yes or no answer indicating emergency room treatment.
• 37. Was the employee hospitalized overnight as a patient?: Yes or no indicating if the employee was hospitalized.
• 38. Reported by: Name of the person reporting the incident.
• 39. Signature: Signature of the person filling out the form.
• 40. Title and telephone #: The title and contact number of the person reporting.

Failing to submit the Illinois Form 45 can lead to penalties and delays in processing workers' compensation claims. Employers may face legal repercussions for non-compliance with reporting regulations.

• Penalties: Employers may incur fines for failing to complete and submit the report timely.
• Delayed Claims Processing: Claims will not be processed until the necessary documentation is submitted.
• Impact on Benefits: Failure to report can hinder the employee's access to workers' compensation benefits.

• 1. Report Workplace Injuries: Used to formally report any injury that occurs on the job.
• 2. Claim Processing: Necessary for initiating claims for worker's compensation.
• 3. Legal Documentation: Serves as a record in the event of legal proceedings related to workplace injuries.