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Description of illinois form 45
ILLINOIS FORM 45 EMPLOYER S FIRST REPORT OF INJURY Employer s FEIN Date of report Please type or print. Case or File Is this a lost workday case Yes Employer s name / No Doing business as Employer s mailing address Nature of business or service SIC code Name of workers compensation carrier/admin. Policy/Contract Self-insured Employee s full name Social Security Employee s e-mail address Dependents Male Birthdate...
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illinois form 45
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