ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY

EMPLOYER:

Employer's Illinois Unemployment Compensation # 

Date of report 

Employer's Name 

Is this a lost workday case? Yes No

Mailing Address

Employer location, if different from mailing address

Street Address

City     State     Zip Code 

Employee's Information

Employee's name

Social Security # 

Street Address

City     State     Zip Code 

Male  Female        Married     Single

Birth date     # Dependents 

Date and time of accident:

Employee's average weekly wage 

Last day employee worked 

Job title or occupation 

Address of accident

Street Address

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

Nature of the injury. 

Part of the 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:

Name 

Street Address

City     State     Zip Code 

Name and address of hospital:

Name 

Street Address

City     State     Zip Code 

Report Prepared by

Title an telephone #