Homepage Fill Out Your Illinois First Report 45 Form
Article Structure

The Illinois First Report 45 form serves as a crucial document for employers when reporting work-related injuries or illnesses. It collects important information about the incident, including the details of the injured employee, such as their name, birthdate, and job title. Employers must indicate the nature of the injury, the circumstances surrounding the accident, and any medical treatment received. Key data points include the date and time of the incident, the last day the employee worked, and whether the accident happened on the employer's premises. Additionally, the form requires employers to specify if the case involves lost workdays, reflecting the severity of the injury. Records must be diligently maintained, as employers have a legal obligation to report injuries that result in the loss of more than three scheduled workdays to the Illinois Workers' Compensation Commission. The form assures confidentiality, and it cannot be used against employers in legal proceedings. Completing this form accurately and promptly is essential for navigating the workers’ compensation process effectively.

Illinois First Report 45 Example

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

Form Characteristics

Fact Name Fact Description
Form Purpose The Illinois First Report 45, known as the Employer's First Report of Injury, is designed to document work-related injuries or illnesses experienced by employees.
Governing Law This form is governed by the Illinois Workers’ Compensation Act, which mandates the reporting of certain workplace injuries.
Lost Workday Case The form includes a critical question regarding whether the case involves lost workdays; this determination guides further reporting obligations.
Employee Details Essential employee information captured includes name, birthdate, gender, marital status, and average weekly wage, ensuring comprehensive reporting.
Accident Reporting Employers must describe the circumstances of the accident, including what the employee was doing and how the accident occurred, to provide context for the injury.
Confidentiality Information submitted through the form is confidential, safeguarding the privacy of the employee while fulfilling reporting requirements.

Guidelines on Utilizing Illinois First Report 45

After completing the Illinois First Report 45 form, you will be required to submit it to the Illinois Workers' Compensation Commission. This process helps ensure that all work-related injuries are documented appropriately, and it allows employees to receive the necessary benefits. Here are the step-by-step instructions to fill out the form correctly:

  1. Begin by typing or printing clearly in the designated sections.
  2. Enter the Employer's FEIN (Federal Employer Identification Number) and the Date of report.
  3. Input the Case or File # assigned to this report.
  4. Indicate whether this is a lost workday case by checking "Yes" or "No."
  5. Fill in the Employer's name and the name you do business as.
  6. Provide the Employer's mailing address, including street address, city, state, and ZIP code.
  7. List the Employer’s email address.
  8. Specify the Nature of business or service and include the SIC code.
  9. Identify the Name of workers' compensation carrier/admin and Policy/Contract #.
  10. Indicate whether your business is self-insured by selecting "Yes" or "No."
  11. Provide Employee's full name and Birthdate.
  12. Complete the Employee's mailing address and Employee's e-mail address.
  13. Check the Gender and Marital status.
  14. List the number of Dependents.
  15. State the Employee's average weekly wage.
  16. Indicate the Job title or occupation.
  17. Record the Date hired and the Time employee began work.
  18. Provide the Date and time of accident.
  19. Note the Last day employee worked.
  20. If applicable, include the Date of death if the employee died as a result of the accident.
  21. Mark whether the accident occurred on the employer's premises by selecting "Yes" or "No."
  22. Fill in the Address of accident.
  23. Describe what the employee was doing when the accident occurred.
  24. Explain how the accident occurred.
  25. Detail the injury or illness sustained, listing the part of the body affected.
  26. Identify what object or substance, if any, directly harmed the employee.
  27. Provide the Name and address of physician/health care professional involved.
  28. If treatment was given away from the worksite, include the name and address of that place.
  29. Indicate whether the employee was treated in an emergency room.
  30. Check whether the employee was hospitalized overnight as an inpatient.
  31. Complete the Report prepared by section including your Signature, Title, and telephone # as well as your Email address.
  32. Review the completed form for accuracy.
  33. Send the completed form to the ILLINOIS WORKERS' COMPENSATION COMMISSION, located at 4500 S. Sixth St. Frontage Rd, Springfield, IL 62703.

What You Should Know About This Form

What is the Illinois First Report 45 form?

The Illinois First Report 45 form is an official document that employers must fill out to report work-related injuries to the Illinois Workers' Compensation Commission. This report is essential for documenting accidents in the workplace and helps ensure that injured employees receive the necessary benefits and care.

Who needs to complete this form?

Employers in Illinois need to complete this form whenever a work-related injury occurs, especially if it results in the loss of more than three scheduled workdays. It records important details about the incident and the employee affected.

What information is required on the form?

The form asks for specific details, including the employer's information, the employee's information, the nature of the injury, how the accident occurred, and the treatment received. Each section must be filled out accurately to ensure the report is valid.

Where do I send the completed form?

Once the form is completed, it should be sent to the Illinois Workers' Compensation Commission at 4500 S. Sixth St. Frontage Rd, Springfield, IL 62703. It's important to ensure that it is sent promptly to meet reporting requirements.

Is this form confidential?

Yes, the information submitted on the Illinois First Report 45 form is confidential. It is kept secure and used only for the purposes of processing workers' compensation claims and ensuring compliance with the Workers’ Compensation Act.

What happens if the employee dies as a result of the accident?

If the employee dies as a result of a work-related accident, the form must still be completed. The date of death should be reported on the form, and this information is critical for any potential claims by the employee’s dependents.

Can I send the form electronically?

The form must be filed with the necessary information included. Whether sent electronically depends on the specific procedures set by the Illinois Workers' Compensation Commission. It's advised to check their website or contact them directly for guidance on submission methods.

What if I make a mistake while filling out the form?

If you realize there is a mistake after submitting the form, contact the Illinois Workers' Compensation Commission as soon as possible. They can provide guidance on correcting errors and ensuring the record is updated appropriately.

Does completing this form affect liability under the Workers’ Compensation Act?

No, filing the Illinois First Report 45 form does not affect an employer's liability under the Workers’ Compensation Act. It serves as a record of the incident without admitting fault or liability.

Common mistakes

When filling out the Illinois First Report 45 form, people often make several common mistakes that can lead to delays in processing or complications later on. Paying attention to details is crucial. One frequent mistake is failing to provide accurate and complete information about the employer’s details, such as the Employer’s FEIN and mailing address. This may seem minor, but it can lead to significant issues when trying to address the claim.

Another common error involves the employee’s personal information. It’s essential to ensure that the employee’s full name, email address, and birthdate are correctly reported. If this information doesn’t match what’s on file, it can complicate communications and verification processes.

Missing out on the "Date and time of accident" is another frequent error. Providing precise details about when the accident occurred is necessary for proper record-keeping and can greatly impact the outcome of the claim. Alongside this, some individuals neglect to clearly explain the circumstances surrounding the accident, forgetting to describe what the employee was doing at the time it occurred.

Additionally, people often overlook the significance of describing the injury or illness accurately. It's vital to clearly detail the part of the body affected and the nature of the injury. Providing vague descriptions can lead to misunderstandings and may prolong the claims process.

Another significant oversight is failing to indicate whether the accident occurred on the employer's premises. While it may seem like a straightforward "yes" or "no," this detail carries weight in determining the claim's eligibility. Similarly, confirming whether the employee received treatment in an emergency room or was hospitalized overnight can affect the processing of the claim, so it should not be skipped.

Lastly, signatures can be a source of error. Some people forget to sign and date the report, which is crucial. The report needs to be formally acknowledged to ensure that everything has been accurately submitted. Missing this step can lead to the report being deemed incomplete.

To avoid these mistakes, take the time to review each section of the Illinois First Report 45 form carefully. Every detail matters. By ensuring accuracy and completeness, you can enhance the likelihood of a smooth processing experience and support the employee effectively during their recovery journey.

Documents used along the form

The Illinois First Report 45 form is an essential document for notifying the Illinois Workers' Compensation Commission about workplace injuries. Alongside this form, there are several other documents that assist in the workers' compensation process. The following list outlines these commonly used forms and documents, providing a brief description of each.

  • Illinois Form 45 (Employer's First Report of Injury): This form documents the details of a workplace injury and is required for reporting to the Illinois Workers' Compensation Commission.
  • Claimant's Application for Adjustment of Claim: This document initiates the claim process for an injured worker. It outlines the nature of the injury and the benefits sought.
  • Medical Reports: These reports from healthcare providers outline the diagnosis, treatment received, and the expected recovery timeline for the injured employee.
  • Employer's Response to Employee's Claim: This document allows the employer to respond to the claim made by the employee, detailing any disagreements or points of clarification.
  • Return-to-Work Form: This form is used to document the employee's ability to resume work. It may specify any restrictions or accommodations needed post-injury.
  • Disability Benefits Application: This application is utilized when an employee seeks compensation for lost wages due to the injury, detailing the duration and extent of the disability.
  • Incident Report: This internal report outlines the details surrounding the incident that caused the injury, typically filled out by a supervisor or manager.
  • Witness Statements: These documents gather accounts from individuals who observed the incident. They can provide valuable context and support for the injured employee's claim.
  • Settlement Agreement: This agreement outlines the terms under which compensation is paid out following a successful claim. It details the amount and any conditions attached to the settlement.

Understanding these forms and documents can help ensure a smoother process in addressing workplace injuries. Proper documentation enhances the ability of both employees and employers to navigate workers' compensation claims effectively.

Similar forms

  • Workers' Compensation Claim Form: Similar to the Illinois First Report 45, this document is used to officially report work-related injuries to the relevant workers' compensation board. It collects essential details about the incident, employee, and employer, ensuring a clear account of the situation for claim processing.

  • Employer's Report of Injury: This form serves a similar purpose in documenting workplace injuries. It includes information about the employer, employee, and specifics of the incident to facilitate workers' compensation claims and ensure compliance with reporting regulations.

  • Incident Report Form: Often used internally, this form provides a detailed account of the circumstances surrounding an accident. Like the Illinois First Report 45, it gathers information about the employee and the nature of the injury, but may also include safety issues and recommendations to prevent future occurrences.

  • OSHA 301 Form: This form is used for recording work-related injuries and illnesses for OSHA reporting purposes. It collects similar information about the employee and the incident, ensuring that employers comply with federal reporting requirements.

  • Claim for Compensation Form: This document is submitted by employees seeking benefits for work-related injuries. It gathers information about the circumstances of the injury and provides a basis for evaluating the compensation claim, paralleling the reporting structure of the Illinois First Report 45.

Dos and Don'ts

When filling out the Illinois First Report 45 form, follow these guidelines to ensure accuracy and compliance:

  • Do ensure all information is accurate. Double-check names, dates, and other details to avoid mistakes.
  • Do provide complete information. Fill out every required field to ensure your report is processed smoothly.
  • Do submit the report promptly. Timely submission helps avoid penalties and keeps you compliant with state laws.
  • Do keep a copy for your records. Retain a copy of the form for your files in case you need to refer to it later.
  • Do follow up on your submission. Confirm that the report has been received by the Illinois Workers' Compensation Commission.
  • Don’t omit important details. Failing to include significant information can lead to delays or disputes.
  • Don’t use unclear language. Be straightforward in your descriptions of the accident and injury.
  • Don’t forget about confidentiality. Ensure sensitive information is handled appropriately and not shared inappropriately.
  • Don’t file late. Missing deadlines can result in penalties and complications with claims.
  • Don’t sign without review. Ensure every detail is accurate before submitting the form.

Misconceptions

Misconceptions about the Illinois First Report 45 form can lead to confusion when it comes to workplace injuries and the accompanying documentation. It's essential to clarify these myths for better understanding. Here are seven common misconceptions:

  • It’s only for severe injuries. Many believe that the Illinois First Report 45 form is only necessary for significant injuries. In reality, it must be filed for any injury that results in more than three lost workdays, regardless of severity.
  • The form is optional. Some individuals think that completing the form is a choice. However, employers are legally required to submit this report for qualifying work-related injuries to maintain compliance with state regulations.
  • It can be submitted anytime. There’s a misconception that the timing of the submission is flexible. In fact, the report should be sent promptly after an injury occurs to ensure accurate and timely processing.
  • Only employers can file the form. While the form is primarily prepared by employers, employees who suffer an injury can also provide necessary details. Collaboration helps ensure that all pertinent information is included.
  • Filing affects legal liability. Some believe that submitting the report may imply guilt or affect the employer’s liability. This is not true. The information provided is confidential and does not influence liability under the Workers' Compensation Act.
  • The report is public information. There’s a notion that reports filed with the Illinois Workers' Compensation Commission are accessible to the public. However, this information is kept confidential to protect the privacy of those involved.
  • Only physical injuries need to be reported. A common misunderstanding is that only physical injuries warrant a report. Mental health issues arising from work-related incidents also need documentation and can be reported using the same form.

By addressing these misconceptions, employers and employees can better navigate the workers' compensation process and ensure that appropriate actions are taken in the event of a workplace injury.

Key takeaways

Here are some essential points to keep in mind when filling out the Illinois First Report 45 form:

  • Accurate Information is Key: Ensure that all the information, such as the employer’s FEIN and employee details, is correct. Any inaccuracies may delay the process.
  • Prompt Reporting: Complete the form as soon as possible after an injury occurs. Timely filing is crucial for compliance and supporting claims.
  • Lost Workdays: Clearly indicate if the case results in lost workdays. This distinction is important for the workers’ compensation process.
  • Details of the Incident: Provide a thorough explanation of how the accident occurred, including what the employee was doing at the time. This helps in assessing the situation accurately.
  • Confidentiality Matters: Remember that the information provided on the form is confidential. Protect the privacy of all parties involved.
  • Health Care Provider Information: List the name and address of the health care professional who treated the employee. This information is important for follow-up care and recordkeeping.
  • Review Before Submission: Check the completed form for any missing information or errors. A thorough review can prevent unnecessary complications.