Workers Compensation Injury Report PDF Details

Workers compensation injury report forms are an important way for employers to document workplace injuries and ensure that employees receive the appropriate medical care. The form helps employers track the dates and circumstances of injuries, as well as their workers' compensation claim status. Completing a workers compensation injury report form can be daunting, but our guide will help make it easy. In this guide, we'll explain what information is required on the form and provide tips for completing it accurately. We'll also discuss common errors made on workers compensation injury reports and how to avoid them.

This quick report can help you determine just how long it will take you to fill out workers compensation injury report, the number of pages it's got, and some additional unique details about the PDF.

QuestionAnswer
Form NameWorkers Compensation Injury Report
Form Length5 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out1 min 27 sec
Other namesworkers compensation injury form, injury report for workers compensation, indiana worker's compensation first report of employee injury illness document, injuries at work compensation form

Form Preview Example

WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS

EMPLOYER (NAME & ADDRESS INCL ZIP)

CARRIER / ADMINISTRATOR CLAIM NUMBER *

 

REPORT PURPOSE CODE *

 

 

 

 

 

 

 

 

JURISDICTION *

JURISDICTION LOG NUMBER *

 

 

 

 

 

 

 

 

INSURED REPORT NUMBER

 

OSHA CASE NUMBER

 

 

 

 

 

 

 

EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT)

 

LOCATION #:

 

 

 

 

 

INDUSTRY CODE

EMPLOYER FEIN

 

 

 

PHONE #

 

 

 

 

 

 

CARRIER / CLAIMS ADMINISTRATOR

CARRIER (NAME AND ADDRESS)

POLICY PERIOD

CLAIMS ADMINISTRATOR (NAME AND ADDRESS)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK IF APPROPRIATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF INSURANCE

 

 

 

PHONE

 

 

 

 

 

 

 

 

 

 

 

(A/C, No, Ext):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(A/C, No, Ext):

 

 

 

 

 

 

 

 

 

 

 

CARRIER FEIN *

 

 

 

 

 

 

POLICY / SELF-INSURED NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADMINISTRATOR FEIN *

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENT NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENT CODE NUMBER:

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE / WAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

SOCIAL SECURITY NUMBER

 

DATE HIRED

 

 

 

STATE OF HIRE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS (INCL ZIP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEX

 

 

MARITAL STATUS

 

 

OCCUPATION / JOB TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MALE

 

 

 

 

UNMARRIED/SINGLE/DIVORCED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEMALE

 

 

 

 

MARRIED

 

 

EMPLOYMENT STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-MAIL ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNKNOWN

 

 

 

 

SEPARATED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

# OF DEPENDENTS

 

 

UNKNOWN

 

 

NCCI CLASS CODE *

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RATE

 

 

 

 

 

 

 

DAY

 

 

MONTH

 

AVERAGE WEEKLY

# DAYS WORKED / WEEK

FULL PAY FOR DAY OF INJURY? (Y / N)

 

 

 

 

 

PER:

 

 

 

 

 

WAGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WEEK

 

 

OTHER:

 

 

 

 

 

 

 

 

 

DID SALARY CONTINUE? (Y / N)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCCURRENCE / TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TIME EMPLOYEE

 

AM

 

DATE OF INJURY / ILLNESS

 

TIME OF OCCURRENCE

 

 

 

 

AM

 

 

LAST WORK DATE

 

DATE EMPLOYER NOTIFIED

DATE DISABILITY BEGAN

BEGAN WORK

 

 

 

 

 

 

 

 

 

 

 

 

 

CANNOT BE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

DETERMINED

 

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACT NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF INJURY / ILLNESS

 

 

 

 

 

 

PART OF BODY AFFECTED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(A/C, No, Ext):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DID INJURY / ILLNESS EXPOSURE

 

 

 

 

 

 

 

TYPE OF INJURY / ILLNESS CODE *

 

 

PART OF BODY AFFECTED CODE *

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCCUR ON EMPLOYER'S PREMISES? (Y / N)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS

EXPOSURE OCCURRED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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? (Y / N)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WERE THEY USED? (Y / N)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN / HEALTH CARE PROVIDER (NAME & ADDRESS)

 

 

 

HOSPITAL OR OFFSITE TREATMENT (NAME & ADDRESS)

 

 

 

INITIAL TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO MEDICAL TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MINOR: BY EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MINOR CLINIC / HOSP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMERGENCY CARE

WITNESS NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WITNESS NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OVERNIGHT HOSPITALIZATION

PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FUTURE MAJOR MEDICAL/

(A/C, No, Ext):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(A/C, No, Ext):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOST TIME ANTICIPATED

DATE ADMINISTRATOR NOTIFIED

 

DATE PREPARED

PREPARER'S NAME

 

 

 

 

 

 

 

TITLE

 

 

 

 

 

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACORD 4 (2013/01)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 5

 

 

 

© 1993-2013 ACORD CORPORATION. All rights reserved.

IAIABC 1A-1 (1/1/02)

 

 

 

 

 

 

 

 

 

 

 

 

 

REPRINTED WITH PERMISSION OF IAIABC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The ACORD name and logo are registered marks of ACORD

 

 

 

 

 

 

 

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.

APPLICABLE IN ALASKA

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 ARIZONA

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 ARKANSAS

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.

APPLICABLE IN CALIFORNIA

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 COLORADO

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.

APPLICABLE IN CONNECTICUT

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 DELAWARE AND OKLAHOMA

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 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.

APPLICABLE IN FLORIDA

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 HAWAII

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.

EMPLOYEE SIGNATURE:

ACORD 4 (2013/01)

Page 2 of 5

APPLICABLE IN IDAHO

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 INDIANA

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 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.

APPLICABLE IN KENTUCKY, LOUISIANA, MAINE, MICHIGAN, NEW JERSEY, NEW MEXICO, NEW YORK, NORTH DAKOTA, PENNSYLVANIA, RHODE ISLAND, SOUTH DAKOTA, VIRGINIA AND WEST VIRGINIA

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 MARYLAND

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 MINNESOTA

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 NEVADA

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.

APPLICABLE IN NEW HAMPSHIRE

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.

APPLICABLE IN OHIO

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.

APPLICABLE IN TENNESSEE

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.

APPLICABLE IN TEXAS

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.

APPLICABLE IN UTAH

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.

APPLICABLE IN WASHINGTON

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:

ACORD 4 (2013/01)

Page 3 of 5

EMPLOYER'S INSTRUCTIONS

DO NOT ENTER DATA IN FIELDS MARKED *

DATES:

Enter all dates in MM/DD/YY format.

INDUSTRY CODE:

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.

OSHA CASE NUMBER:

Transfer the case number from the OSHA 300 log after you record the case there.

CARRIER:

The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant.

CLAIMS ADMINISTRATOR:

Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administer- ing the claim.

AGENT NAME & CODE NUMBER:

Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy.

OCCUPATION / JOB TITLE:

This is the primary occupation of the claimant at the time of the accident or exposure.

EMPLOYMENT STATUS:

 

 

 

Indicate the employee's work status. The valid choices are:

 

Full-Time

On Strike

Unknown

Volunteer

Part-Time

Disabled

Apprenticeship Full-Time

Seasonal

Not Employed

Retired

Apprenticeship Part-Time

Piece Worker

DATE DISABILITY BEGAN:

The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise deigned by statute.

CONTACT NAME / PHONE NUMBER:

Enter the name of the individual at the employer's premises to be contacted for additional information.

TYPE OF INJURY / ILLNESS:

Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm).

PART OF BODY AFFECTED:

Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back).

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. Maintenance Department or Client's office at 452 Monroe St., Washington, DC 26210)

If the accident or illness exposure did not occur on the employer's premises, enter address or location. Be specific.

ACORD 4 (2013/01)

Page 4 of 5

ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(eg. Acetylene cutting torch, metal plate)

List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operat- ing when the injury or illness occurred. Be specific, for example: decorator's scaffolding, electric sander, paintbrush, and paint.

Enter "NA" for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee's injury or illness.

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(eg. Cutting metal plate for flooring)

Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting.

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter "NA" for not applicable if employee was not engaged in a work process (eg. walking along a hallway).

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:

(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.)

Describe how the injury or illness / abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker's right wrist was broken in the fall.

DATE RETURN(ED) TO WORK:

Enter the date following the most recent disability period on which the employee returned to work.

ACORD 4 (2013/01)

Page 5 of 5

How to Edit Workers Compensation Injury Report Online for Free

Filling out files with our PDF editor is more straightforward compared to anything else. To modify injury report for workers compensation the form, there isn't anything for you to do - just continue with the actions down below:

Step 1: On this web page, click the orange "Get form now" button.

Step 2: You can now modify the injury report for workers compensation. The multifunctional toolbar will let you insert, delete, modify, and highlight content material as well as perform several other commands.

It is essential to provide the following information to prepare the file:

form compensation report gaps to complete

You have to submit the EMAIL, ADDRESS, PHONE RATE, MALE, FEMALE, UNKNOWN, MARRIED, SEPARATED, EMPLOYMENT, STATUS OF, DEPENDENTS UNKNOWN, NCC, I, CLASS, CODE PER, DAY, WEEK, and MONTH box with the expected data.

Completing form compensation report part 2

In the DATE, RETURNED, TO, WORK IF, FATAL, GIVE, DATE, OF, DEATH INITIAL, TREATMENT DATE, PREPARED PREPARER, S, NAME TITLE, WITNESS, NAME, PHONE, AC, No, Ext NO, MEDICAL, TREATMENT MINOR, BY, EMPLOYER MINOR, CLINIC, HO, SP EMERGENCY, CARE PHONE, NUMBER REPRINTED, WITH, PERMISSION, OF, IAI, ABC Page, of and A, CORD, CORPORATION, All, rights, reserved field, identify the essential data.

stage 3 to filling out form compensation report

Inside the paragraph EMPLOYEE, SIGNATURE A, CORD and Page, of describe the rights and responsibilities of the parties.

Filling out form compensation report stage 4

Finalize the template by reading these particular fields: EMPLOYEE, SIGNATURE A, CORD and Page, of

Entering details in form compensation report step 5

Step 3: In case you are done, press the "Done" button to upload your PDF file.

Step 4: Make copies of the form - it can help you refrain from upcoming difficulties. And fear not - we cannot share or watch your data.

Watch Workers Compensation Injury Report Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .