ACORD 4 (2011/07)

ACORD 4 (2011/07) rev. 6-30-2011
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Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 4 (2011/07)
Workers Compensation - First
Report of Injury or Illness
ACORD 4, Workers Compensation First Report of Injury or Illness, is
used to report a work-related injury. 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. The second and third pages of the form contain required state specific
fraud warnings. Instructions to the employer regarding completion of the form are
contained on the fourth and fifth pages of the form.
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.
IDENTIFICATION SECTION Zip)
Employer (Name & Address incl
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Address 1
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION Address 2
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION City
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION State
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION Zip
Enter code: The named insured's mailing address postal code.
IDENTIFICATION SECTION Industry Code
Enter code: The Standard Industry Classification code assigned to the business activity (if
known). 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
of Management and Budget.
ACORD 4 (2011/07) rev. 6-30-2011
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Employer FEIN
Enter identifier: The tax identifier of the named insured.
IDENTIFICATION SECTION Number *
Carrier / Administrator Claim
Enter identifier: The identifier assigned to the claim by the insurer. As used here, the
employer should not enter data in this field.
IDENTIFICATION SECTION Report Purpose Code *
Enter code: The code identifying the purpose of the report. This code is entered by the
carrier or the state workers comp board that receives the form. As used here, the
employer should not enter data in this field.
IDENTIFICATION SECTION Jurisdiction *
Enter code: The state or organization that has final disposition of this claim. The source of
this code list is the U.S. Postal service except for injuries/Illness under Federal Jurisdiction
which use the Workers' Compensation Insurance Organizations (WCIO) Code list. As
used here, the employer should not enter data in this field.
IDENTIFICATION SECTION Jurisdiction Log Number *
Enter identifier: The identifier assigned to the claim by the jurisdiction. As used here, the
employer should not enter data in this field.
IDENTIFICATION SECTION Insured Report Number
Enter identifier: The identifier assigned to the claim by the named insured/employer.
IDENTIFICATION SECTION OSHA Case Number
Enter identifier: The case number assigned by OSHA (Occupational Safety and Health
Administration), if applicable.
IDENTIFICATION SECTION different)
Employer's Location Address (If
Enter text: The first address line of the physical location.
IDENTIFICATION SECTION Address 2
Enter text: The second address line of the physical location.
IDENTIFICATION SECTION City
Enter text: The city of the physical location.
IDENTIFICATION SECTION State
Enter code: The state or province of the physical location.
IDENTIFICATION SECTION Zip
Enter code: The postal code of the physical location.
IDENTIFICATION SECTION Location #
Enter number: The producer assigned number of the location.
IDENTIFICATION SECTION Phone #
Enter number: The primary phone number of the location.
CARRIER / CLAIMS
ADMINISTRATOR
Carrier (Name and Address)
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name. As used here, this is the licensed
business entity issuing a contract of insurance and assuming financial responsibility on
behalf of the employer of the claimant.
ACORD 4 (2011/07) rev. 6-30-2011
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Section Name
Field Name
Field and/or Section Description
CARRIER / CLAIMS
ADMINISTRATOR
Address 1
Enter text: The first line of the insurer's mailing address.
CARRIER / CLAIMS
ADMINISTRATOR
Address 2
Enter text: The second line of the insurer's mailing address.
CARRIER / CLAIMS
ADMINISTRATOR
City
Enter text: The city of the insurer's mailing address.
CARRIER / CLAIMS
ADMINISTRATOR
State
Enter code: The state or province of the insurer's mailing address.
CARRIER / CLAIMS
ADMINISTRATOR
Zip
Enter code: The postal code of the insurer's mailing address.
CARRIER / CLAIMS
ADMINISTRATOR
Phone (A/C, No, Ext)
Enter number: The primary phone number of the insurer. As used here, the telephone
number of the licensed business entity issuing a contract of insurance and assuming
financial responsibility on behalf of the employer of the claimant. (Include area code and
extension if applicable)
CARRIER / CLAIMS
ADMINISTRATOR
Policy Period Start
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
CARRIER / CLAIMS
ADMINISTRATOR
Policy Period Expire
Enter date: The date on which the terms and conditions of the policy will expire.
CARRIER / CLAIMS
ADMINISTRATOR
Self Insurance Checkbox
Check the box (if applicable): Indicates if the insured is self-insured, in whole or in part.
CARRIER / CLAIMS
ADMINISTRATOR
Claims Administrator (Name,
Address & Phone No.)
Enter text: The name of the carrier, third party administrator, state fund, or self-insured
responsible for administering the claim.
CARRIER / CLAIMS
ADMINISTRATOR
Address 1
Enter text: The first address line of the claim administrator's mailing address.
CARRIER / CLAIMS
ADMINISTRATOR
Address 2
Enter text: The second address line of the claim administrator's mailing address.
CARRIER / CLAIMS
ADMINISTRATOR
City
Enter text: The city of the claim administrator's mailing address.
CARRIER / CLAIMS
ADMINISTRATOR
State
Enter code: The state or province code of the claim administrator's mailing address.
CARRIER / CLAIMS
ADMINISTRATOR
Zip
Enter code: The postal code of the claim administrator's mailing address.
CARRIER / CLAIMS
ADMINISTRATOR
Phone (A/C, No, Ext)
Enter number: The primary phone number of the claim administrator.
CARRIER / CLAIMS
ADMINISTRATOR
Carrier FEIN *
Enter identifier: The tax identifier of the insurer.
ACORD 4 (2011/07) rev. 6-30-2011
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Section Name
Field Name
Field and/or Section Description
CARRIER / CLAIMS
ADMINISTRATOR
Policy/Self-Insured Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
CARRIER / CLAIMS
ADMINISTRATOR
Administrator FEIN *
Enter identifier: The tax identifier of the claim administrator.
CARRIER / CLAIMS
ADMINISTRATOR
Agent Name
Enter text: The full name of the producer/agency.
CARRIER / CLAIMS
ADMINISTRATOR
Agent Code Number
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer. As used here, this information can be found on your insurance policy.
EMPLOYEE / WAGE
Name
Enter text: The employer's last name (surname).
EMPLOYEE / WAGE
First Name
Enter text: The employee's first name (given name).
EMPLOYEE / WAGE
Middle Initial
Enter text: The employee's middle name or initial (other given name).
EMPLOYEE / WAGE
Address (Incl Zip)
Enter text: The first address line of the employee's mailing address.
EMPLOYEE / WAGE
City
Enter text: The city of the employee's mailing address.
EMPLOYEE / WAGE
State
Enter code: The state or province code of the employee's mailing address.
EMPLOYEE / WAGE
Zip
Enter code: The postal code of the employee's mailing address.
EMPLOYEE / WAGE
E-Mail Address
Enter text: The e-mail address for the employee.
EMPLOYEE / WAGE
Phone
Enter number: The primary phone number of the employee.
EMPLOYEE / WAGE
Date of birth
Enter date: The employee's birth date.
EMPLOYEE / WAGE
Social Security Number
Enter identifier: The tax identifier of the employee.
EMPLOYEE / WAGE
Date Hired
Enter date: The hire date of the employee.
EMPLOYEE / WAGE
State of Hire
Enter code: The state in which the individual was hired.
EMPLOYEE / WAGE
Sex - Male
Check the box (if applicable): Indicates the employee is male.
EMPLOYEE / WAGE
Sex - Female
Check the box (if applicable): Indicates the employee is female.
EMPLOYEE / WAGE
Sex - Unknown
Check the box (if applicable): Indicates the gender of the employee is unknown.
EMPLOYEE / WAGE
# of Dependents
Enter number: The number of dependents of the employee.
EMPLOYEE / WAGE
Marital Status -
Unmarried/Single/Divorced
Check the box (if applicable): Indicates the employee is single.
EMPLOYEE / WAGE
Married
Check the box (if applicable): Indicates the employee is married.
EMPLOYEE / WAGE
Separated
Check the box (if applicable): Indicates the employee is separated from their spouse.
EMPLOYEE / WAGE
Unknown
Check the box (if applicable): Indicates the employee's marital status is unknown.
EMPLOYEE / WAGE
Occupation / Job Title
Enter text: The occupation of the employee. As used here, the occupation of the employee
at the time of the accident or exposure.
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Section Name
Field Name
Field and/or Section Description
EMPLOYEE / WAGE
Employment Status
Enter code: Identifies the employment status of this individual. The valid choices are: Full-
Time, Part-Time, Not Employed, Officer, On Strike, Disabled, Retired, Unknown,
Apprenticeship Full-Time, Apprenticeship Part-Time, Volunteer, Seasonal and Piece
Worker.
EMPLOYEE / WAGE
NCCI Class Code *
Enter code: The rating classification code that the employee's estimated remuneration
was assigned to.
EMPLOYEE / WAGE
Rate
Enter amount: The employee's average wage amount. As used here, the rate at the time
of the accident or exposure.
EMPLOYEE / WAGE
Day
Check the box (if applicable): Indicates the average wage amount is paid per day.
EMPLOYEE / WAGE
Week
Check the box (if applicable): Indicates the average wage amount is paid per week.
EMPLOYEE / WAGE
Month
Check the box (if applicable): Indicates the average wage amount is paid monthly.
EMPLOYEE / WAGE
Other (checkbox)
Check the box (if applicable): Indicates the average wage amount is paid at a frequency
other than those listed.
EMPLOYEE / WAGE
Other (blank field)
Enter code: Indicates the frequency at which the average wage amount is paid.
EMPLOYEE / WAGE
Average Weekly Wages
Enter amount: The average weekly wages for the past 52 weeks.
EMPLOYEE / WAGE
# Days Worked / Week
Enter number: The number of days worked per week.
EMPLOYEE / WAGE
Full Pay for Day of Injury?
Enter Y for a Yes response. Input N for No response. Indicates if the injured/ill
employee will be paid for the full day of the injury/illness.
EMPLOYEE / WAGE
Did salary continue?
Enter Y for a Yes response. Input N for No response. Indicates if salary continuance
applies.
OCCURRENCE /
TREATMENT
Time Employee Began Work
Enter time: The time of day that work began for the employee on the day of the
injury/illness.
OCCURRENCE /
TREATMENT
A.M.
Check the box (if applicable): Indicates the employee began work in the morning.
OCCURRENCE /
TREATMENT
P.M.
Check the box (if applicable): Indicates the employee began work in the afternoon or
evening.
OCCURRENCE /
TREATMENT
Date of Injury / Illness
Enter date: The date that the loss occurred. As used here, the date the claimant actually
sustained the injury or exposure (which is the date that the loss occurred).
OCCURRENCE /
TREATMENT
Cannot Be Determined
Check the box (if applicable): Indicates the incident time could not be determined.
OCCURRENCE /
TREATMENT
Time of Occurrence
Enter time: The approximate time that the loss occurred.
OCCURRENCE /
TREATMENT
A.M.
Check the box (if applicable): Indicates the loss occurred in the morning.
OCCURRENCE /
TREATMENT
P.M.
Check the box (if applicable): Indicates the loss occurred in the afternoon or evening.
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Section Name
Field Name
Field and/or Section Description
OCCURRENCE /
TREATMENT
Last work date
Enter date: The date on which the employee last worked.
OCCURRENCE /
TREATMENT
Date Employer Notified
Enter date: The date the employer was notified or became aware of the employee's work
related disability/incapacity.
OCCURRENCE /
TREATMENT
Date Disability Began
Enter date: The first day on which the claimant originally lost time from work due to the
occupation injury or disease or as otherwise stated by statute.
OCCURRENCE /
TREATMENT
Contact Name
Enter text: The full name (First, Middle, Last) of the individual to be contacted as a
representative of the insured on all subsequent business relating to this incident. No entry
is needed if the 'Contact Insured' option is checked.
OCCURRENCE /
TREATMENT
Phone (A/C, No, ext)
Enter number: The loss contact's primary telephone number including area code.
OCCURRENCE /
TREATMENT
Type of Injury / Illness
Enter text: The description of the nature of the injury or illness being reported.
OCCURRENCE /
TREATMENT
Part of Body Affected
Enter text: The description of the part of the body to which the injury occurred.
OCCURRENCE /
TREATMENT
Did Injury / Illness Exposure Occur
on Employer's Premises?
Enter Y for a Yes response. Input N for No response. Indicates if the accident, injury or
illness occurred on the employer's premises.
OCCURRENCE /
TREATMENT
Type of Injury / Illness Code *
Enter code: The industry code that corresponds to the nature of the injury sustained by the
claimant.
OCCURRENCE /
TREATMENT
Part of Body Affected Code *
Enter code: The industry code that corresponds to the affected body part.
OCCURRENCE /
TREATMENT
Department or Location Where
Accident or Illness Exposure
Occurred
Enter text: The 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
Enter text: The description of 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.
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Section Name
Field Name
Field and/or Section Description
OCCURRENCE /
TREATMENT
Specific Activity the Employee
Was Engaged in When the
Accident or Illness Exposure
Occurred
Enter text: The 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
Enter text: 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
Enter text: The description of 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).
OCCURRENCE /
TREATMENT
Cause of Injury Code *
Enter code: The industry code identifying the general cause of loss, occurrence, injury or
illness. There are multiple sources for this code list such as the Workers' Compensation
Insurance organizations (WCIO), Insurance Services Office (ISO), Bureau of Labor
Statistics.
OCCURRENCE /
TREATMENT
Date Return(ed) to Work
Enter date: The date the claimant returned to work or is expected to return to work.
OCCURRENCE /
TREATMENT
If Fatal, give Date of Death
Enter date: The employee's date of death.
OCCURRENCE /
TREATMENT
Were Safeguards or Safety
Equipment Provided?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Were safeguards or safety equipment provided?.
OCCURRENCE /
TREATMENT
Were Safeguards Or Safety
Equipment Provided Used? - Yes
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Were safeguards or safety equipment provided used?.
OCCURRENCE /
TREATMENT
Physician / Health Care Provider
(Name and Address)
Enter text: The full name of the physician.
OCCURRENCE /
TREATMENT
Address 1
Enter text: The physician's first mailing address line.
OCCURRENCE /
TREATMENT
Address 2
Enter text: The physician's second mailing address line.
OCCURRENCE /
TREATMENT
City
Enter text: The physician's mailing address city name.
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Section Name
Field Name
Field and/or Section Description
OCCURRENCE /
TREATMENT
State
Enter code: The physician's mailing address state or province code.
OCCURRENCE /
TREATMENT
Zip
Enter code: The physician's mailing address postal code.
OCCURRENCE /
TREATMENT
Hospital or Offsite Treatment
(Name and Address)
Enter text: The name of the hospital.
OCCURRENCE /
TREATMENT
Address 1
Enter text: The hospital's mailing address line one.
OCCURRENCE /
TREATMENT
Address 2
Enter text: The hospital's mailing address line two.
OCCURRENCE /
TREATMENT
City
Enter text: The hospital's mailing address city.
OCCURRENCE /
TREATMENT
State
Enter text: The hospital's mailing address state or province code.
OCCURRENCE /
TREATMENT
Zip
Enter text: The hospital's mailing address line postal code.
OCCURRENCE /
TREATMENT
Initial Treatment - No Medical
Treatment
Check the box (if applicable): Indicates there was no initial treatment when the claimant
was injured.
OCCURRENCE /
TREATMENT
Minor : By Employer
Check the box (if applicable): Indicates the initial treatment was minor and done by the
employer.
OCCURRENCE /
TREATMENT
Minor Clinic / Hosp
Check the box (if applicable): Indicates the initial treatment was minor and done by a clinic
or hospital.
OCCURRENCE /
TREATMENT
Emergency Care
Check the box (if applicable): Indicates emergency care was required when the claimant
was injured.
OCCURRENCE /
TREATMENT
Overnight Hospitalization
Check the box (if applicable): Indicates overnight hospitalization was required when the
claimant was injured.
OCCURRENCE /
TREATMENT
Future Major Medical / Lost Time
Anticipated
Check the box (if applicable): Indicates future major medical/lost time is anticipated for the
claimant.
OCCURRENCE /
TREATMENT
Witness Name
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger. As used here the person who witnessed how the injury, or illness/abnormal
health condition occurred.
OCCURRENCE /
TREATMENT
Phone (A/C, No. Ext)
Enter number: The primary phone number of a person that was a witness to the incident.
OCCURRENCE /
TREATMENT
Witness Name
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger. As used here the person who witnessed how the injury, or illness/abnormal
health condition occurred.
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Section Name
Field Name
Field and/or Section Description
OCCURRENCE /
TREATMENT
Phone (A/C, No. Ext)
Enter number: The primary phone number of a person that was a witness to the incident.
OCCURRENCE /
TREATMENT
Date Administrator Notified
Enter date: The date the employer was notified or became aware of the employee's work
related disability/incapacity.
OCCURRENCE /
TREATMENT
Date Prepared
Enter date: The date the claim form was completed
OCCURRENCE /
TREATMENT
Preparer's Name
Enter text: The name of the individual that prepared the claim form.
OCCURRENCE /
TREATMENT
Preparer's Title
Enter text: The title of the individual that prepared the claim form.
OCCURRENCE /
TREATMENT
Phone Number
Enter number: The phone number of the individual that prepared the claim form.
SIGNATURE
Signature
Sign here: Accommodates the signature of the employee.
SIGNATURE
Signature
Sign here: Accommodates the signature of the employee.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).