ACORD Forms : How to Complete a Workers Comp First Report 4Workers Comp First Report of Injury or Illness 4
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.
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 November 1, 1998, the following states are reported to accept ACORD 4. Consult your company about use in other states.
In addition, Wisconsin accepts ACORD 4WI, Wisconsin Employer's First Report of Injury or Illness.
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