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ILLINOIS FORM 45: EMPLOYER'S FIRST REPORT OF INJURY. Please Date of report If the employee died as a result of the accident, give the date of death. VWC file number. (formerly: Employer's First Report of Accident). The boxes. Virginia Workers' Compensation Commission to the right Insurer code or PEO Ref. EMPLOYER'S FIRST REPORT OF INJURY OR ILLNESS. (Filing this form State of Utah 0 Labor Commission 0 Division of Industrial Accidents. 160 East 300 It is the responsibility of the employer to report an alleged injury, whether or not the employer agrees with the employee's claim or not. This form must be filed Employer's First Report of Occupational Injury or Illness Employer's Location Address (if different) was using when accident or illness exposure occurred:. EMPLOYER'S FIRST REPORT OF INJURY. Employee's Employer's mailing address. City What was the employee doing just before the accident occurred?3. Employer. Employer's Legal Name. Federal Employer Identification Number (FEIN) If none of the criteria apply, you must still report the accident, but may use The employer is required to file an Employer's First Report of Injury or Illness List nature of accident or exposure, e.g., fall from scaffold, contact with radiation, Specify part of machine, etc. This form must be completed by the employer, the employer's representative or the insurer and filed within 10 days after the notice of a work-related injury, occupational illness/disease or if the occurrence resulted in death to the worker. EMPLOYER'S FIRST REPORT OF INJURY OR DISEASE Employee Name (First, Middle, Last) County and State Where Accident or Exposure Occurred?
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