ACORD™

WORKERS COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS

EMPLOYER (NAME & ADDRESS)
NAME
ADDRESS
CITY STATE ZIP

SIC CODE
 EMPLOYER FEIN
CARRIER/ADMINISTRATOR CLAIM NUMBER *
 REPORT PURPOSE CODE *
JURISDICTION *
 JURISDICTION CLAIM NUMBER *
INSURED REPORT NUMBER
LOCATION #:
PHONE #:
EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)
CARRIER/CLAIMS ADMINISTRATOR
CARRIER
NAME
ADDRESS
CITY STATE ZIP
PHONE #
POLICY PERIOD
TO 		CLAIMS ADMINISTRATOR
NAME
ADDRESS
CITY STATE ZIP
PHONE #

CHECK IF APPROPRIATE
SELF INSURED
CARRIER FEIN *
 POLICY/SELF-INSURED NUMBER
 ADMINISTRATOR FEIN *
EMPLOYEE/WAGE
NAME
ADDRESS
CITY STATE ZIP
PHONE #

DATE OF BIRTH
SOCIAL SECURITY #
DATE HIRED
 STATE OF HIRE
SEX
MALE
FEMALE
UNKNOWN		 MARITAL STATUS
UNMARRIED/SINGLE/DIVORCED
MARRIED
SEPARATED
UNKNOWN

OCCUPATION/JOB TITLE
EMPLOYMENT STATUS
# OF DEPENDENTS
NCCI CLASS CODE *
RATE:

PER:
DAY MONTH
WEEK ER
AVG WEEKLY WAGES
 # DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY?
YES NO
DID SALARY CONTINUE?
YES NO
OCCURRENCE/TREATMENT
TIME EMPLOYEE BEGAN WORK AM PM  DATE OF INJURY/ILLNESS  TIME OF OCCURRENCE AM PM
LAST WORK DATE  DATE EMPLOYER NOTIFIED  DATE DISABILITY BEGAN
CONTACT NAME / PHONE NUMBER
 TYPE OF INJURY/ILLNESS
 PART OF BODY AFFECTED
DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER’S PREMISES? YES NO TYPE OF INJURY/ILLNESS CODE *
 PART OF BODY AFFECTED CODE *
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED
 ALL EQUIPMENT, MATERIALS OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED
 WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED
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
CAUSE OF INJURY CODE *
DATE RETURN(ED) TO WORK
 IF FATAL, GIVE DATE OF DEATH
 WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?
 YES NO
WERE THEY USED? YES NO
PHYSICIAN/HEALTH CARE PROVIDER
NAME
ADDRESS
CITY STATE ZIP
HOSPITAL
NAME
ADDRESS
CITY STATE ZIP
INITIAL TREATMENT

NO MEDICAL TREATMENT
MINOR: BY EMPLOYER
MINOR CLINIC/HOSP
EMERGENCY CARE
HOSPITALIZED > 24 HRS
FUTURE MAJOR MEDICAL/
        LOST TIME ANTICIPATED
WITNESS (NAME & PHONE)
DATE ADMINISTRATOR NOTIFIED
 DATE PREPARED
 PREPARER’S NAME & TITLE
 PHONE NUMBER
ACORD 4 (2001/02) © ACORD CORPORATION 1993