ACORD 4 Form Fillable – First Report of Injury or Illness
ACORD 4
Workers Compensation – First Report of Injury or Illness
|
Form Number: |
ACORD 4 Form (2019/09) |
|
Category: |
Property & Casualty |
|
Last Updated: |
September 2019 |
|
Page Count: |
2 pages |
|
File Format: |
PDF, Fillable PDF |
ACORD 4 Form
A workplace is often surrounded by hazardous equipment. If an employee becomes ill or sustains a work-related injury, the employer must file the initial report of injury with the insurance carrier. The Acord 4 form is a legal document that enables the immediate initiation of a claim for a workplace injury. It is often used by insurance agents, employers, risk management professionals, or third-party administrators.
Form Preview
Benefits Of Accord 4 Workers Compensation Form
Standardized Documentations
It serves as a legal document to report a workplace injury, ensuring compliance and consistency for insurance providers.
Supports Workplace Safety
The Acord First Report of Injury form helps employers improve workplace safety to avoid incidents.
Faster Claim Process
The insurer will get all important details related to injury or illness, which helps speed up the claim process.
Protects All Parties
It ensures protection for both employer and employee for an unforeseen incident, audit, or investigation.
Key Sections of the Acord 4 Fillable Form
Employer Information
Includes the company’s name, address, contact number, and FEIN.
Employee Information
Records of ill or injured employees, including name, job title, hiring date, nature of job, and wage information.
Accident or Illness Details
Contains a brief description of an accident, including when, where, and how the incident occurred.
Injury Details
Provide comprehensive information about the type of injury and which part is affected the most.
Medical Treatment Information
Prior information about the first aid, medical provider, and where the treatment took place.
Signature
The employer must have a signature with the date and submit it as soon as possible.
How to Complete Acord 4 Form
- Fill in the name of the insurance carrier, policy number, and claim number.
- Write the business name, address, contact person’s name, phone number, and Federal Employer Identification Number (FEIN).
- Write the employee’s name, address, phone number, job title, hiring date, date of birth, social security number, and wage.
- Mention the date and time of injury, location, description, type of injury, and affected body parts.
- Write the name and address of the physician, the type of care, and the time of initial treatment.
- Write the last date of work, return date to work, and estimated time off due to injury, to indicate the work status.
- Mention the name and contact information of your insurance provider.
- The employer signs the form with the date of completion.
Frequently Asked Questions
Related Forms
ACORD 3
Property Loss Notice
Standardized form for reporting property losses or damages
ACORD 20
Certificate of Aviation Liability
commonly used to certify liability insurance coverage for aviation-related risks
ACORD 21
Certificate of Aircraft Insurance
Standardized form used for reporting aircraft insurance coverage