ILLINOIS FORM 85:  EMPLOYER'S SUPPLEMENTARY REPORT OF INJURY                                                               Please type or print.
Employer's FEIN                              Date of report           Case or File #                                   This report is  
                                                                                                                              Supplementary   /   Final
Employer's name                                                       Doing business as 

Employer's full 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
Insurer's mailing address                                             City                                             State           Zip code

Employee's full name                                                                                                   Birthdate

Employee's full mailing address                                       Employee's email address                             

Date of injury/diagnosis        Date of first payment        Employee's average weekly wage                             # Dependents

Period of disability                                        If the employee died as a result of the accident, give the date of death.

   BENEFIT  INFORMATION
                                             Please provide a comprehensive history of payments.
        Payment Type            Weekly                      Number of                           Benefit Paid                                    Total
    (TTD, medical, etc.)        Payment                     Weeks                            From       Through                                Payments

                                                                                               Grand total                             $
Was this case closed by the Industrial Commission?          If so, how was the case resolved?
          Yes   /     No                                            Settlement contract   /     Arbitration decision   /     Commission decision
Report prepared by                           Signature                                       Title  telephone #,       , and email address

Please send this form to:  ILLINOIS WORKERS' COMPENSATION COMMISSION  4500 S. SIXTH ST. FRONTAGE ROAD  SPRINGFIELD, IL  62703-5118 
In addition to the Employer's First Report of Injury (IC45), employers shall file this report when 1) benefits begin or are stopped;
2) there is a change in the employee's status; 3) final compensation is made.  This information is confidential.    IC85 8/12