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Forms

Click on a form in the table below to go to the form description, form view button (pdf format), and download button to save the Microsoft Word form to your computer.  Tab through the downloadable form to enter information.  Print and fax form to the IRMA Claims Department at (708) 562-0400 or email to claims@irmarisk.org
 

NON-WORKERS' COMPENSATION ACCIDENT REPORT          

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Please fill out in ink within 24 hours of the loss. When the form is completed, forward it to the claims coordinator for signature and date. Please complete all areas on form. Below are some explanations of areas on the form that may need clarification. Please fax all accident reports to (708) 562-0400.

CLAIMS SUPPLEMENTAL INFORMATION TRANSMITTAL           

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In an effort to help us facilitate your claim, please complete this form and send it with all additional information on:

  • claims already submitted to IRMA, orBack To Top
  • any lawsuit being submitted.

WORKERS' COMPENSATION INJURY REPORTING PROCEDURES

 Procedures For Reporting and Maintaining Employee Injury Records

When an accident occurs, it must be reported within five workdays. Timely reporting of an accident is mandatory. Insuring full employee benefits and reducing liability costs is dependent upon proper reporting. Having a record is good documentation in case something more serious develops later. It is the responsibility of each employee to report all accidents. This should be a requirement and it should be enforced evenly.

A. Workers' Compensation Accidents (Doctor/Hospital Treatment)

Accidents resulting in injuries that require medical/hospital treatment will require the employee's supervisor to complete the Illinois Industrial Commission's First Report of Injury - Form 45 and immediately forward to IRMA, along with a completed Supervisor's Investigation Report and Workers' Compensation Wage Statement and other required reports for processing of workers' compensation benefits for the injured employee. i.e. Employee's Statement of Incident Form (if applicable-not mandatory)
 
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First Report of Injury - Form 45

Workers' Compensation Wage Statement

 First Prescription Fill Letter 

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B. Non-Workers' Compensation Accidents (First Aid/Incident)

Employees involved in accidents during the course of their employment, resulting in minor injuries that may or may not require first aid, must immediately report it to their supervisor using the  Incident/First Aid Report . An example of an incident would be when an employee cuts his hand on something and only requires the injured area to be cleansed and a bandage applied. When an Incident/First Aid Report is submitted, it should be date stamped and kept in a binder by departments. In addition, the safety coordinator or person who is processing accident reports should develop an accident log which will provide a summary of all the incidents. The log can be a supplement to the annual injury and illness summary required by O.S.H.A.. The following is an example of how your incident log might look.

Date Received Date of Accident Name of Employee Type of Accident Aid
Rendered
Dept /
Job Title
9/22/87 9/18/87 S. Smith Fall No Bldg. Maint./Elec
1/08/88 1/03/88 J. Leno Cut Yes Personnel/Secretary
 

WORKERS' COMPENSATION COMMISSION HANDBOOK ON WORKERS' COMPENSATION & OCCUPATIONAL DISEASES  

 
See Handbook on Illinois Workers' Compensation Commission website by clicking on above link.

SUPERVISOR’S INVESTIGATION REPORT           

Please email accident report to IRMA promptly to claims@irmarisk.org or fax to (708) 562-0400.

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INCIDENT/FIRST AID REPORT                  

This report will be used for any accident or incident, which may or may not have required first aid, but did not require clinic or hospital treatment.  This report should be completed no later than the end of the work shift of the employee involved.  This report does not need to be submitted to IRMA.

NON-EMPLOYEE INCIDENT REPORT           

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This report should be used by any non-employee involved in an accident or incident occurring on municipal property, which required first-aid or hospital treatment, resulted in the non-employee complaining of discomfort as a result of the incident, or resulted in damage to their personal property.

WITNESS STATEMENT (Employee/Non-Employee)      

This report is to be used by the driver or anyone who witnesses an accident or incident for both Workers' Compensation and Liability claims.

MEDICAL REPORT FORM-DUTY STATUS REPORT     

This report should be completed by the injured employee's physician and returned to the member. This form indicates the physician's opinion regarding whether or not the employee is able to perform his/her normal job duties and the extent of the disability. The physician also provides a medical opinion regarding work tolerance limitations.

AUTHORIZATION FOR MEDICAL RECORDS & COMMUNICATION RELEASE   

This report should be completed by the injured employee at the time of injury.  The form can then be submitted to IRMA with the initial claim or as soon as the injured employee signs and dates the form.

PHYSICAL DEMANDS SUMMARY                                        

The sole purpose of this summary is to serve as a guideline to assist the medical provider, functional capacity evaluation facility, claims representative and management in the facilitation of the return to work process.  This form should be added to any job description that does not already include the specific physical demands of the job.

Bloodborne Pathogen Claims   

Bloodborne pathogen claims require the same forms as all other workers' compensation claims. Correspondence following the initial submission regarding these claims should include the claim number, but should not include the name of the claimant.