ILLINOIS FORM 45:  EMPLOYER'S FIRST REPORT OF INJURY                                              Please type or print.

Employer's Illinois Unemployment Compensation #

Date of report

Case or File #

Employer's name

Is this a lost workday case?

 Yes  No

Doing business under the name of

Mailing address

City

State

Zip code

Employer location, if different from mailing address

Nature of business or service

SIC code

Total Number of Employees at the Location where illness or Injury Occurred                

Name of workers' compensation carrier/admin.

Policy/Contract #

Self-insured?

 Yes No

County of accident site

Employee's name (last, middle, first)

Social Security #

Employee's street address

City

State

Zip code

 Male Female

 Married  Single

Birthdate

# Dependents

Date & time of accident

Employee's average weekly wage

Last day employee worked

Job title or occupation

Address of accident

City

State

Zip code

Did the employee die as a result of the accident?

Yes No

If yes, give the date of death

Did the accident occur on the employer's premises?

 Yes No

This accident resulted in

Occupational injury            Occupational disease

Nature of the injury

Part of body affected (be specific)

What task was the employee performing when the accident occurred?

Object or substance responsible for accident, if any (source)

How did accident occur?

What hazardous conditions, if any, contributed to the accident?

What unsafe act, if any, contributed to the accident?

Have medical services been rendered to the employee?

 Yes         No

Has the employee been hospitalized?

Yes       No

Name and address of physician

City

State

Zip code

Name and address of hospital

City

State

Zip code

Report prepared by

Signature

Title and telephone #

Please send this form to the ILLINOIS INDUSTRIAL COMMISSION 701 S. SECOND STREET SPRINGFIELD, IL 62704          .       IC45 1/00

By law, employers shall maintain 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 sense. This information is confidential.