Fillable ILLINOIS IC45 (National American Insurance Company)

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ILLINOIS IC45 (National American Insurance Company)

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The ILLINOIS IC45 (National American Insurance Company) form is 1 page long and contains:

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Country of origin: US
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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
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
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ILLINOIS IC45 (National American Insurance Company)

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Completed 29 July 2021

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