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WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR (National American Insurance Company)

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ACORD 4 (2013/01)
IAIABC 1A-1 (1/1/02)
EMPLOYER FEIN
EMPLOYER (NAME & ADDRESS INCL ZIP)
INDUSTRY CODE
JURISDICTION LOG NUMBER *JURISDICTION *
REPORT PURPOSE CODE *CARRIER / ADMINISTRATOR CLAIM NUMBER *
LOCATION #:
PHONE #
EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT)
INSURED REPORT NUMBER OSHA CASE NUMBER
WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS
RATE
PER:
DAY
WEEK
MONTH
OTHER:
AVERAGE WEEKLY
WAGES
EMPLOYEE / WAGE
DID SALARY CONTINUE? (Y / N)
FULL PAY FOR DAY OF INJURY? (Y / N)
# DAYS WORKED / WEEK
EMPLOYMENT STATUS
OCCUPATION / JOB TITLE
# OF DEPENDENTSPHONE
E-MAIL ADDRESS:
ADDRESS (INCL ZIP)
UNKNOWN
FEMALE
MALE
SEX
SEPARATED
MARRIED
UNMARRIED/SINGLE/DIVORCED
UNKNOWN
MARITAL STATUS
STATE OF HIREDATE HIREDSOCIAL SECURITY NUMBERDATE OF BIRTHNAME (LAST, FIRST, MIDDLE)
NCCI CLASS CODE *
ADMINISTRATOR FEIN *CARRIER FEIN *
CARRIER / CLAIMS ADMINISTRATOR
(A/C, No, Ext):
PHONE
CARRIER (NAME AND ADDRESS)
(A/C, No, Ext):
PHONE
CLAIMS ADMINISTRATOR (NAME AND ADDRESS)
TO
POLICY PERIOD
SELF INSURANCE
CHECK IF APPROPRIATE
POLICY / SELF-INSURED NUMBER
AGENT CODE NUMBER:AGENT NAME:
PM
AM
BEGAN WORK
TIME EMPLOYEE
DATE OF INJURY / ILLNESS
DETERMINED
CANNOT BE
PM
AM
TIME OF OCCURRENCE
DATE EMPLOYER NOTIFIED
LAST WORK DATE
DATE DISABILITY BEGAN
(A/C, No, Ext):
PHONE
CONTACT NAME TYPE OF INJURY / ILLNESS PART OF BODY AFFECTED
DID INJURY / ILLNESS EXPOSURE
OCCUR ON EMPLOYER'S PREMISES? (Y / N)
IF FATAL, GIVE DATE OF DEATH
WERE THEY USED? (Y / N)
WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? (Y / N)
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
DATE ADMINISTRATOR NOTIFIED
CAUSE OF INJURY CODE *
PART OF BODY AFFECTED CODE *TYPE OF INJURY / ILLNESS CODE *
OCCURRENCE / TREATMENT
PHONE NUMBER
TITLEPREPARER'S NAME
DATE PREPARED
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
(A/C, No, Ext):
PHONE
WITNESS NAME:
(A/C, No, Ext):
PHONE
WITNESS NAME:
PHYSICIAN / HEALTH CARE PROVIDER (NAME & ADDRESS)
DATE RETURN(ED) TO WORK
HOSPITAL OR OFFSITE TREATMENT (NAME & ADDRESS)
LOST TIME ANTICIPATED
FUTURE MAJOR MEDICAL/
OVERNIGHT HOSPITALIZATION
EMERGENCY CARE
MINOR CLINIC / HOSP
MINOR: BY EMPLOYER
NO MEDICAL TREATMENT
INITIAL TREATMENT
The ACORD name and logo are registered marks of ACORD
REPRINTED WITH PERMISSION OF IAIABC
Page 1 of 5 © 1993-2013 ACORD CORPORATION. All rights reserved.
APPLICABLE IN ALABAMA
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any
combination thereof.
ACORD 4 (2013/01)
APPLICABLE IN THE DISTRICT OF COLUMBIA
Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information
materially related to a claim was provided by the applicant.
For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
Pursuant to S. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured,
prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim
under an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, or misleading
information concerning any fact or thing material to the claim commits a felony of the third degree, punishable as provided in
S. 775.082, S. 775.083, or S. 775.084, Florida Statutes.
APPLICABLE IN DELAWARE AND OKLAHOMA
This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material
fact related to a claimed injury may be guilty of a felony.
APPLICABLE IN COLORADO
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the
purpose of obtaining or denying workers compensation benefits or payments is guilty of a felony.
APPLICABLE IN ARKANSAS
APPLICABLE IN ARIZONA
A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete,
or misleading information may be prosecuted under state law.
APPLICABLE IN CALIFORNIA
APPLICABLE IN HAWAII
APPLICABLE IN FLORIDA
Any person who knowingly and with intent to injure, defraud, or deceive any Insurer, files a statement of claim containing any false,
incomplete or misleading information is guilty of a felony. The lack of such a statement shall not constitute a defense against
prosecution under this section. *Delaware Statutes Regulations: Del #C Section 913(B)
APPLICABLE IN CONNECTICUT
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages.
Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with
regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the
Department of Regulatory Agencies.
Any person or entity who willfully and knowingly makes any material false statement or representation or who willfully and knowingly
omits or conceals any material information, or who willfully and knowingly employs any device, scheme or artifice for the purpose of
obtaining any benefit or payment, or for the purpose of defeating or wrongfully decreasing any claim for benefit or payment or
obtaining or avoiding workers' compensation coverage or avoiding payment of the proper insurance premium (or who aids and abets
for either said purpose), under this chapter shall be guilty of a Class D. felony.
For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or
fraudulent claim for payment of a loss is subject to criminal and civil penalties.
APPLICABLE IN ALASKA
EMPLOYEE SIGNATURE:
Page 2 of 5
Any person who knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim
Containing any False, Incomplete or Misleading information is Guilty of a Felony.
APPLICABLE IN IDAHO
ACORD 4 (2013/01)
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
APPLICABLE IN KANSAS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it
will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of,
an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or
other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially
false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act.
Any person who knowingly and with intent to defraud any insurance company or another person files a statement of claim containing
any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and subjects the person to criminal and [NY: substantial] civil penalties. In LA, ME and VA,
insurance benefits may also be denied.
APPLICABLE IN KENTUCKY, LOUISIANA, MAINE, MICHIGAN, NEW JERSEY, NEW MEXICO, NEW YORK,
NORTH DAKOTA, PENNSYLVANIA, RHODE ISLAND, SOUTH DAKOTA, VIRGINIA AND WEST VIRGINIA
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding
the company. Penalties include imprisonment, fines and denial of insurance benefits.
EMPLOYEE SIGNATURE:
APPLICABLE IN WASHINGTON
APPLICABLE IN UTAH
APPLICABLE IN TEXAS
APPLICABLE IN TENNESSEE
APPLICABLE IN OHIO
APPLICABLE IN NEW HAMPSHIRE
APPLICABLE IN NEVADA
A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
APPLICABLE IN MARYLAND
A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading
information commits a felony.
APPLICABLE IN INDIANA
APPLICABLE IN MINNESOTA
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or
misleading information concerning a material fact is guilty of a felony.
Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
fines and confinement in state prison.
Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim
for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other
professional services is guilty of a crime and may be subject to fines and confinement in state prison.
It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers compensation transaction for
the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a
claim containing a false or deceptive statement is guilty of insurance fraud.
Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false,
incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
Page 3 of 5
ACORD 4 (2013/01) Page 4 of 5
Transfer the case number from the OSHA 300 log after you record the case there.
OSHA CASE NUMBER:
This is the code which represents the nature of the employer's business which is contained in the Standard
Industrial Classification Manual or the North American Industry Classification System published by the Federal
Office of Management and Budget.
DO NOT ENTER DATA IN FIELDS MARKED *
EMPLOYER'S INSTRUCTIONS
Enter all dates in MM/DD/YY format.
DATES:
of the employer of the claimant.
The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf
CARRIER:
ing the claim.
Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administer-
CLAIMS ADMINISTRATOR:
your insurance policy.
Enter the name of your insurance agent and his/her code number if known. This information can be found on
AGENT NAME & CODE NUMBER:
This is the primary occupation of the claimant at the time of the accident or exposure.
OCCUPATION / JOB TITLE:
Piece WorkerApprenticeship Part-TimeRetiredNot Employed
SeasonalApprenticeship Full-TimeDisabledPart-Time
VolunteerUnknownOn StrikeFull-Time
Indicate the employee's work status. The valid choices are:
EMPLOYMENT STATUS:
as otherwise deigned by statute.
The first day on which the claimant originally lost time from work due to the occupation injury or disease or
DATE DISABILITY BEGAN:
Enter the name of the individual at the employer's premises to be contacted for additional information.
CONTACT NAME / PHONE NUMBER:
Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm).
TYPE OF INJURY / ILLNESS:
Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back).
PART OF BODY AFFECTED:
specific.
If the accident or illness exposure did not occur on the employer's premises, enter address or location. Be
(eg. Maintenance Department or Client's office at 452 Monroe St., Washington, DC 26210)
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
INDUSTRY CODE:
ACORD 4 (2013/01) Page 5 of 5
listed do not have to be directly involved in the employee's injury or illness.
Enter "NA" for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items
paintbrush, and paint.
ing when the injury or illness occurred. Be specific, for example: decorator's scaffolding, electric sander,
List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operat-
(eg. Acetylene cutting torch, metal plate)
OCCURRED:
ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE
such as sanding ceiling woodwork in preparation for painting.
Describe the specific activity the employee was engaged in when the accident or illness exposure occurred,
(eg. Cutting metal plate for flooring)
OCCURRED:
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE
(eg. walking along a hallway).
such as building maintenance. Enter "NA" for not applicable if employee was not engaged in a work process
Describe the work process 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:
worker's right wrist was broken in the fall.
Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The
name any objects or substance that directly injured the employee or made the employee ill. For example:
Describe how the injury or illness / abnormal health condition occurred. Include the sequence of events and
against the hot metal.)
(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed
EMPLOYEE ILL:
AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE
HOW INJURY OR ILLNESS / ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS
Enter the date following the most recent disability period on which the employee returned to work.
DATE RETURN(ED) TO WORK:
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Completed 29 July 2021

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