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                No     
 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                No      
 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                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?                       Was the employee hospitalized overnight as an inpatient? 

                Yes                No                                               Yes                No     
 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