MCIM Claim Forms - Illinois
First Report of Injury
NOTE: Adobe Acrobat Approval, Standard, or Professional version 5 or newer is required for submitting this form by email.
Please report injuries to MCIM as soon as possible.
NOTE: Adobe Acrobat Approval, Standard, or Professional version 5 or newer is required for submitting this form by email.
Please report injuries to MCIM as soon as possible.
Wage Statement
Declaración del Salario
This form is necessary in all lost time cases where wages will be paid to the injured worker. The Workers' Compensation Act requires that we have 52 weeks of prior wage information whenever possible to determine the rate at which they will be paid.
Declaración del Salario
This form is necessary in all lost time cases where wages will be paid to the injured worker. The Workers' Compensation Act requires that we have 52 weeks of prior wage information whenever possible to determine the rate at which they will be paid.
