Acord 4 Form – Workers Compensation-First Report of Injury or Illness
Acord 4 Fillable Form
An Acord 4 form is an initial reporting document to inform employers, insurance carriers, and state authorities about workplace injury or illness of workers. This report aims to provide appropriate care and compensation to the injured person. This form uniforms the information to understand and process efficiently.
You can obtain this fillable blank first report of injury or illness form by clicking the download button here. Moreover, you will understand the importance of this form and the step-by-step guidance you need to fill out with additional details.
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Why is the ACORD 4 Fillable Form Important?
This form is used in the United States for workers compensation and has the following importance,
Ensures Timely Reporting
The accurate information on this form meets the workers’ compensation law criteria and ensures that penalties and delays in the claims process are avoided.
Facilitate Employee Care
In-time reporting of injury or illness ensures the employer understands that the injured employee requires appropriate care and facilities.
Reduce Legal Risk
This form contains the incident record, and timely submission reduces the legal risk.
Communication
The accurate and concise information on the form enhances the communication between employers, insurers, and regulators to understand the incident.
How To Obtain a Fillable ACORD 4 First Report of Injury or Illness Form
Contact Insurance Agent
You need to consult with an insurance agent and arrange a meeting. Gather all the vital information about the company and its workers. Provide it to the agent and ask him/her to complete the form. He/she will develop this form under the Association for Cooperative Operations Research and Development (ACORD) policy.
Official Website
You must visit the Acord’s official website. Type the name or number of the current form in the search bar. Fill it out online and get a print, or click the download button to save it on your device quickly. Later, submit it to the authorised representative for the instant process.
Third-Party Website
Most third-party websites (Forms Dude) offer all essential insurance forms. To visit the homepage, you must type www.formsdude.com in the browser. Type the form’s name or number (Acord 4 Form) in the search bar at the top. Click the download button or fill it out here and get a print to provide this form to the authenticated person for processing.
Step-by-Step Instructions for Filling Out the Blank Acord 4 Form
The step-by-step instructions will help you to complete the form accurately to avoid delays:
1- Employer Information
In this section, you must write the employer’s name, mailing address, city name, state name, city’s postal code, and industry code. Also, write the administrator’s claim number, report purpose code, jurisdiction, log number, report number, location, and phone number.
2- Carrier/Claims Administrator Information
Write the carrier’s and administrator’s name, address, phone number, policy period, and agent’s name and code.
3- Employee/Wage
In this section, write the employee’s name, address, email address, phone number, date of birth, gender, social security number, marital status, and number of dependants. Also, write the hiring date, hiring state, occupation, employment status, NCCI class code, and rate.
4- Occurrence/Treatment
In this section, write concise information about the incident and treatment details. Also, mention the witness for medical treatment.
5- Signature
Get the applicant’s signature and submit it after review.
Additional Details to Consider While Filling Out Acord 4 Form
These details play a vital role in the accurate completion of the form:
Accuracy
It is crucial to recheck the details mentioned on the form for accuracy. This will help reduce the delays in the process.
Concise Information
You must provide information about the incident in a precise manner to avoid superlative details.
Engage Witnesses
The witnesses’ testimony will help you to provide incident information and strengthen the validity of claims.
Review State Requirements
This form is acceptable in the United States. However, some states require additional documents. You must consult your insurance provider to avoid delays and ask for additional documents.
FAQs
What is the Acord 4 Form?
It is a valid reporting document to get workers’ compensation for workplace illness or injury.
What Information is Required to Complete the Acord 4?
To complete this form, it is essential to collect the employer, employees, incident description, witness information, and medical treatment information.
Are There Penalties for Late Filing of the Acord 4?
Yes, if the employer files this form late, he might face fines or liability issues.
Is The Acord 4 Used in All States?
Yes, it is widely accepted in the United States. However, some states require additional documents to approve the claim.