FIRST REPORT OF INJURY OR ILLNESS - Applied …

1 1993-2012 ACORD CORPORATION. All rights 1 of 5 REPRINTED WITH PERMISSION OF IAIABCThe ACORD name and logo are registered marks of ACORDINITIAL TREATMENTNO MEDICAL TREATMENTMINOR: BY EMPLOYERMINOR CLINIC / HOSPEMERGENCY CAREOVERNIGHT HOSPITALIZATIONFUTURE MAJOR MEDICAL/LOST TIME ANTICIPATEDHOSPITAL OR OFFSITE TREATMENT (NAME & ADDRESS)DATE RETURN(ED) TO WORKPHYSICIAN / HEALTH CARE PROVIDER (NAME & ADDRESS)WITNESS NAME:PHONE(A/C, No, Ext):WITNESS NAME:PHONE(A/C, No, Ext):EXPOSURE OCCURREDWORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESSEXPOSURE OCCURREDSPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESSOR ILLNESS EXPOSURE OCCURREDALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENTDEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURREDDATE PREPAREDPREPARER'S NAMETITLEPHONE NUMBEROCCURRENCE / TREATMENTTYPE OF INJURY / ILLNESS CODE *PART OF BODY AFFECTED CODE *CAUSE OF INJURY CODE *DATE ADMINISTRATOR NOTIFIEDINJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILLHOW INJURY OR ILLNESS / ABNORMAL HEALTH CONDITION OCCURRED.

2 DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLYWERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? (Y / N)WERE THEY USED? (Y / N)IF FATAL, GIVE DATE OF DEATHDID INJURY / ILLNESS EXPOSUREOCCUR ON EMPLOYER'S PREMISES? (Y / N)PART OF BODY AFFECTEDTYPE OF INJURY / ILLNESSCONTACT NAMEPHONE(A/C, No, Ext):DATE DISABILITY BEGANLAST WORK DATEDATE EMPLOYER NOTIFIEDTIME OF OCCURRENCEAMPMCANNOT BEDETERMINEDDATE OF INJURY / ILLNESSTIME EMPLOYEEBEGAN WORKAMPMAGENT NAME:AGENT CODE NUMBER:POLICY / SELF-INSURED NUMBERCHECK IF APPROPRIATESELF INSURANCEPOLICY PERIODTOCLAIMS ADMINISTRATOR (NAME AND ADDRESS)PHONE(A/C, No, Ext):CARRIER (NAME AND ADDRESS)PHONE(A/C, No, Ext).

3 CARRIER / CLAIMS ADMINISTRATORCARRIER FEIN *ADMINISTRATOR FEIN *NCCI CLASS CODE *NAME (LAST, FIRST , MIDDLE)DATE OF BIRTHSOCIAL SECURITY NUMBERDATE HIREDSTATE OF HIREMARITAL STATUSUNKNOWNUNMARRIED/SINGLE/DIVORCEDMA RRIEDSEPARATEDSEXMALEFEMALEUNKNOWNADDRES S (INCL ZIP)E-MAIL ADDRESS:PHONE# OF DEPENDENTSOCCUPATION / JOB TITLEEMPLOYMENT STATUS# DAYS WORKED / WEEKFULL PAY FOR DAY OF INJURY ? (Y / N)DID SALARY CONTINUE? (Y / N)EMPLOYEE / WAGEAVERAGE WEEKLYWAGESOTHER:MONTHWEEKDAYPER:RATEWOR KERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESSOSHA CASE NUMBERINSURED REPORT NUMBEREMPLOYER'S LOCATION ADDRESS (IF DIFFERENT)PHONE #LOCATION #:CARRIER / ADMINISTRATOR CLAIM NUMBER * REPORT PURPOSE CODE *JURISDICTION *JURISDICTION LOG NUMBER *INDUSTRY CODEEMPLOYER (NAME & ADDRESS INCL ZIP)EMPLOYER FEINIAIABC 1A-1 (1/1/02)ACORD 4 (2012/05)Page 2 of 5 EMPLOYEE SIGNATURE:APPLICABLE IN ALASKAFor your protection, Arizona law requires the following statement to appear on this form.

4 Any person who knowingly presents a false orfraudulent claim for payment of a loss is subject to criminal and civil person or entity who willfully and knowingly makes any material false statement or representation or who willfully and knowinglyomits or conceals any material information, or who willfully and knowingly employs any device, scheme or artifice for the purpose ofobtaining any benefit or payment, or for the purpose of defeating or wrongfully decreasing any claim for benefit or payment orobtaining or avoiding workers' compensation coverage or avoiding payment of the proper insurance premium (or who aids and abetsfor either said purpose), under this chapter shall be guilty of a Class D.

5 Is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose ofdefrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts orinformation to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant withregard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within theDepartment of Regulatory IN CONNECTICUTAny person who knowingly and with intent to injure, defraud, or deceive any Insurer.

6 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 againstprosecution under this section. *Delaware Statutes Regulations: Del #C Section 913(B)APPLICABLE IN FLORIDAAPPLICABLE IN HAWAIIAPPLICABLE IN IDAHOAPPLICABLE IN CALIFORNIAA 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 IN ARIZONAAPPLICABLE IN ARKANSASAny person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for thepurpose of obtaining or denying workers compensation benefits or payments is guilty of a IN COLORADOThis form must be completed in its entirety.

7 Any person who intentionally misrepresents or intentionally fails to disclose any materialfact related to a claimed INJURY may be guilty of a IN DELAWARE AND OKLAHOMAP ursuant to S. , 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 claimunder an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, or misleadinginformation concerning any fact or thing material to the claim commits a felony of the third degree, punishable as provided inS.

8 , S. , or S. , Florida your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is acrime punishable by fines or imprisonment, or person who knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of ClaimContaining any False, Incomplete or Misleading information is Guilty of a : It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any otherperson. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false informationmaterially related to a claim was provided by the IN THE DISTRICT OF COLUMBIAACORD 4 (2012/05)

9 Page 3 of 5 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 person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files aclaim containing a false or deceptive statement is guilty of insurance is a crime to knowingly provide false, incomplete or misleading information to any party to a workers compensation transaction forthe purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claimfor disability compensation or medical benefits, or submits a false or fraudulent REPORT or billing for health care fees or otherprofessional services is guilty of a crime and may be subject to fines and confinement in state person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject tofines and confinement in state to NRS.

10 Any person who knowingly and willfully files a statement of claim that contains any false, incomplete ormisleading information concerning a material fact is guilty of a IN MINNESOTAAPPLICABLE IN INDIANAA person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleadinginformation commits a IN MARYLANDA person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a IN NEVADAAPPLICABLE IN NEW HAMPSHIREAPPLICABLE IN OHIOAPPLICABLE IN TENNESSEEAPPLICABLE IN TEXASAPPLICABLE IN UTAHAPPLICABLE IN WASHINGTONEMPLOYEE SIGNATURE:It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defraudingthe company.