| Section Name | Field Name | Field and/or Section Description |
| ACORD, in conjunction with the IAIABC (International Association of Industrial Accident Boards & Commissions) developed this standard First Report. The form tracks with the IAIABC and ANSI X12 EDI standard for reporting Workers Compensation losses. | ||
| The form is designed as a first notice of a claim for injury or illness by an employee. In nearly all cases, the form is completed by the employer and sent directly to the insurer or to the state workers compensation board. It contains information about the employer, insurance carrier, employee, the occurrence leading to the injury or illness, and the nature of injury or illness. Instructions to the employer regarding completion of the form are contained on the third and fourth pages of the form. | ||
| TITLE ACORD 4 (2008/01) | Workers Compensation – First Report of Injury or Illness | Although the form is accepted by insurers in all states, each jurisdiction mandates the form to be used within that state with respect to the report made to the workers compensation board. . This version of ACORD 4 is accepted in many jurisdictions. It is anticipated that this number will continue to increase significantly as states adopt the IAIABC and ANSI X12 EDI Standard. |
| As of January 1, 2005, the following states are reported to accept ACORD 4. Consult your company about use in other states. | ||
| Arkansas | ||
| Connecticut | ||
| Idaho | ||
| Illinois | ||
| Mississippi Montana | ||
| New Jersey Rhode Island | ||
| South Carolina | ||
| Utah | ||
| TITLE | Workers Compensation – First Report of Injury or Illness | In addition, Wisconsin accepts ACORD 4 WI, Wisconsin Employer’s First Report of Injury or Illness. |
| This is the code which represents the nature of the employer’s business which is | ||
| contained in the Standard Industrial Classification Manual published by the Federal Office | ||
| IDENTIFICATION SECTION | Industry Code | of Management and Budget |
| Section Name | Field Name | Field and/or Section Description |
| IDENTIFICATION SECTION | Employer FEIN | This is the Federal Employer Identification Number |
| Carrier/Administrator Claim | ||
| IDENTIFICATION SECTION | Number * | Do not enter data in fields marked * |
| IDENTIFICATION SECTION | Report Purpose Code * | Do not enter data in fields marked * |
| IDENTIFICATION SECTION | Jurisdiction * | Do not enter data in fields marked * |
| IDENTIFICATION SECTION | Jurisdiction Claim Number * | Do not enter data in fields marked * |
| IDENTIFICATION SECTION | Insured Report Number | Enter report number assigned by the employer. |
| IDENTIFICATION SECTION | OSHA Case Number | Enter the case number assigned by OSHA (if applicable) |
| Employer’s Location Address (If | ||
| IDENTIFICATION SECTION | different) | Indicate the actual location address of the employer, if different. |
| IDENTIFICATION SECTION | Location # | Location number, if any, shown on the policy. |
| IDENTIFICATION SECTION | Phone # | Indicate the employer’s telephone number, including area code. |
| CARRIER/CLAIMS | Carrier (Name, Address & Phone | The licensed business entity issuing a contract of insurance and assuming financial |
| ADMINISTRATOR | Number) | responsibility on behalf of the employer of the claimant. |
| CARRIER/CLAIMS | Date on which the terms and conditions of the policy commenced and the date on which | |
| ADMINISTRATOR | Policy Period | the terms and conditions of the policy will or have expire(d).. |
| CARRIER/CLAIMS | ||
| ADMINISTRATOR | Check if Appropriate | Check box if self insured. |
| CARRIER/CLAIMS | Claims Administrator (Name, | Enter the name of the carrier, third party administrator, state fund, or self-insured |
| ADMINISTRATOR | Address & Phone No.) | responsible for administering the claim. |
| CARRIER/CLAIMS | ||
| ADMINISTRATOR | Carrier FEIN * | Do not enter data in fields marked * |
| CARRIER/CLAIMS | ||
| ADMINISTRATOR | Policy/Self-Insured Number | Policy number or self-insured number, if applicable. |
| CARRIER/CLAIMS | ||
| ADMINISTRATOR | Administrator FEIN * | Do not enter data in fields marked * |
| CARRIER/CLAIMS | Enter the name of your insurance agent and his/her code number if known. This | |
| ADMINISTRATOR | Agent Name and Code Number | information can be found on your insurance policy. |
| Section Name | Field Name | Field and/or Section Description |
| EMPLOYEE/WAGE | Name (Last, First, Middle) | Enter name of employee making the claim. |
| EMPLOYEE/WAGE | Address (Incl Zip) | Enter address of the employee making the claim. Include zip code. |
| EMPLOYEE/WAGE | Date of birth | Date of birth of the employee making the claim. (MM/DD/YYYY) |
| EMPLOYEE/WAGE | Social Security Number | Social Security Number of the employee making the claim. |
| EMPLOYEE/WAGE | Date Hired | Indicate the date of hire of the employee making the claim. (MM/DD/YYYY) |
| EMPLOYEE/WAGE | State of Hire | Indicate the state in which the employee making the claim was hired. |
| EMPLOYEE/WAGE | Sex | Indicate the sex of the employee in the appropriate check box. |
| EMPLOYEE/WAGE | Marital Status | Indicate the marital status of the employee in the appropriate check box. |
| EMPLOYEE/WAGE | Occupation/Job Title | This is the primary occupation of the claimant at the time of the accident or exposure. |
| EMPLOYEE/WAGE | Employment Status | Indicate the claimant’s work status. The valid choices are: Full-Time, Part-Time, Not Employed, On Strike, Disabled, Retired, Unknown, Apprenticeship Full-Time, Apprenticeship Part-Time, Volunteer, Seasonal and Piece Worker. |
| EMPLOYEE/WAGE | NCCI Class Code * | Do not enter data in fields marked * |
| EMPLOYEE/WAGE | Rate | Indicate the claimant’s salary at the time of the accident or exposure. Further Indicate whether this salary is per day, per week, etc. |
| EMPLOYEE/WAGE | Average Weekly Wages | Average weekly wages for the past 52 weeks. |
| EMPLOYEE/WAGE | Full Pay for Day of Injury ? | Indicate if the claimant received full pay for the day of the injury or exposure. |
| EMPLOYEE/WAGE | Did salary continue? | Indicate if the claimant continued to receive salary after the day of the injury or exposure. |
| OCCURRENCE/TREATMENT | Time Employee Began Work | Indicate the time the claimant began work on the day of the injury or exposure. Further indicate if a.m. or p.m. |
| OCCURRENCE/TREATMENT | Date of Injury/Illness | Indicate the date the claimant actually sustained the injury or exposure. |
| OCCURRENCE/TREATMENT | Time of Occurrence | Indicate the time the claimant actually sustained the injury or exposure. Further indicate if a.m. or p.m. |
| OCCURRENCE/TREATMENT | Last work date | Indicate the date the claimant last came to work. |
| OCCURRENCE/TREATMENT | Date Disability Began | The first day on which the claimant originally lost time from work due to the occupationinjury or disease or as otherwise stated by statute. |
| OCCURRENCE/TREATMENT | Contact Name/Phone Number | Enter the name of the individual at the employer’s premises to be contacted for additional information |
| OCCURRENCE/TREATMENT | Type of Injury or Illness | Briefly describe the nature of the injury/illness, (e.g., lacerations to the forearm). |
| OCCURRENCE/TREATMENT | Part of Body Affected | Indicate the part of body affected by the injury/illness, (e.g., right arm, lower back) |
| OCCURRENCE/TREATMENT | Did Injury/Illness Exposure Occur on Employer’s Premises? | Indicate whether the injury or illness exposure occurred on the employer’s premises. |
| OCCURRENCE/TREATMENT | Type of Injury/Illness Code * | Do not enter data in fields marked * |
| OCCURRENCE/TREATMENT | Part of Body Affected Code * | Do not enter data in fields marked * |
| Section Name | Field Name | Field and/or Section Description |
| OCCURRENCE/TREATMENT | Department or Location Where Accident or Illness Exposure Occurred | Department or location where accident or illness exposure occurred (e.g., maintenance department or client’s office at 452 Monroe St., Washington, DC 26210). If the accident or illness exposure did not occur on the employer’s premises, enter address or location. Be specific. |
| OCCURRENCE/TREATMENT | All Equipment, Materials, or Chemicals Employee was Using When Accident or Illness Exposure Occurred | All equipment, materials, or chemicals employee was using when accident or illness exposure occurred (e.g., acetylene cutting torch, metal plate). List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush and paint. Enter “NA” for not applicable if no equipment, materials or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee’s injury or illness. |
| OCCURRENCE/TREATMENT | Specific Activity the Employee Was Engaged in When the Accident or Illness Exposure Occurred | Specific activity the employee was engaged in when the accident or illness exposure occurred, (e.g., Cutting metal plate for flooring). Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting. |
| OCCURRENCE/TREATMENT | Work Process the Employee Was Engaged in When Accident or Illness Exposure Occurred | Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process, e.g., walking along a hallway. |
| OCCURRENCE/TREATMENT | How Injury or Illness/Abnormal Health Condition Occurred. Describe the Sequence of events and Include Any Objects or Substances that Directly Injured the Employee or Made the Employee Ill | Describe how injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill, (e.g., Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against hot metal). For example, worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker’s right wrist was broken in the fall. |
| OCCURRENCE/TREATMENT | Date Return(ed) to Work | Indicate the date following the claimant returned or is expected to return to work. (MM/DD/YYYY) |
| OCCURRENCE/TREATMENT | If Fatal, give Date of Death | If claimant’s injury/illness resulted in death, indicate date of death. (MM/DD/YYYY) |
| OCCURRENCE/TREATMENT | Were Safeguards or Safety Equipment Provided? | Indicate your answer in the appropriate check box. |
| OCCURRENCE/TREATMENT | Were They Used? | Indicate your answer in the appropriate check box. |
| OCCURRENCE/TREATMENT | Physician/Health Care Provider (Name and Address) | Indicate the name and address of the physician/health care provider who treated or is treating the claimant. |
| Section Name | Field Name | Field and/or Section Description |
| OCCURRENCE/TREATMENT | Hospital or Offsite Treatment (Name and Address) | Indicate the name and address of the hospital or offsite treatment facility, if applicable, who treated the claimant. |
| OCCURRENCE/TREATMENT | Initial Treatment | Indicate by checking the appropriate box, what course of action was taken when the claimant was injured. |
| OCCURRENCE/TREATMENT | Witnesses (Name & Phone #) | Indicate the name and phone number of individuals who witnessed how the injury or illness/abnormal health condition occurred. |
| OCCURRENCE/TREATMENT | Date Prepared | Indicate the date the Workers Compensation claim form was completed |
| OCCURRENCE/TREATMENT | Preparer’s Name and Title | Indicate the name and title of the individual who prepared the claim form. |
| OCCURRENCE/TREATMENT | Phone Number | Indicate the telephone number of the individual who prepared the claim form. Include area code and extension, if applicable. |