Report a Workers' Compensation Claim Online

For a Workers' Compensation Claim only.

Employer's First Report of Injury

Employer's FEIN

Date of report

Case or File#

Is this a lost workday case?

Employer's name

Doing business as

Employer's Phone (including Area Code)

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?

Employee's full name

Employee's Birthdate

Employee's Social Security Number

Employee's mailing address

Employee's Phone (Including Area Code)

Employee's e-mail address

Gender

Marital Status

# Dependents

Employee's average weekly wage

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?

Address of accident

What was the employee doing when the accident occured?

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 work site, 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?

Report prepared by

Title and telephone #

Email address

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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