ACORD 4 WI (2003/04)

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 12/30/2008.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 4 WI (2003/04)
Wisconsin Employer's First Report
of Injury or Disease
ACORD 4 WI, Wisconsin Employer's First Report of Injury or
Disease, is used to report a work-related injury which causes permanent or temporary
disability resulting in compensation for lost time. Instructions for the completion of
ACORD 4 WI are found on page 2 of this form.
EMPLOYEE INFORMATION Name (First, Middle, Last)
Enter text: The employee's first name (given name).
EMPLOYEE INFORMATION
Enter text: The employee's middle name or initial (other given name).
EMPLOYEE INFORMATION
Enter text: The employer's last name (surname).
EMPLOYEE INFORMATION Social Security Number
Enter identifier: The tax identifier of the employee.
EMPLOYEE INFORMATION Sex Male
Check the box (if applicable): Indicates the employee is male.
EMPLOYEE INFORMATION Sex Female
Check the box (if applicable): Indicates the employee is female.
EMPLOYEE INFORMATION Number
Employee Home Telephone
Check the box (if applicable): Indicates the employee is married.
EMPLOYEE INFORMATION Employee Street Address
Enter text: The first address line of the employee's mailing address.
EMPLOYEE INFORMATION City
Enter text: The city of the employee's mailing address.
EMPLOYEE INFORMATION State
Enter code: The state or province code of the employee's mailing address.
EMPLOYEE INFORMATION Zip
Enter code: The postal code of the employee's mailing address.
EMPLOYEE INFORMATION Occupation
Enter text: The occupation of the employee.
EMPLOYEE INFORMATION Birth Date Month
Enter number: The month of the employee's birth.
EMPLOYEE INFORMATION Birth Date Day
Enter number: The day of the month of the employee's birth.
EMPLOYEE INFORMATION Birth Date Year
Enter year: The year of the employee's birth.
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Section Name
Field Name
Field and/or Section Description
EMPLOYEE INFORMATION Date of Hire
Enter date: The hire date of the employee.
EMPLOYEE INFORMATION or exposure occurred
County and State where accident
Enter text: The loss location's county name.
EMPLOYEE INFORMATION
Enter code: The loss location's state or province code.
EMPLOYER INFORMATION Employer Name
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
EMPLOYER INFORMATION WI Unemployment Ins. Acct. No.
Enter identifier: The named insured's state unemployment account number.
EMPLOYER INFORMATION Self-Insured? Yes
Check the box (if applicable): Indicates the insured is self-insured, in whole or in part.
EMPLOYER INFORMATION Self-Insured? No
Check the box (if applicable): Indicates the insured is not self-insured, in whole or in part.
EMPLOYER INFORMATION Product)
Nature of Business (Specific
Enter text: The description of the nature/type of business.
EMPLOYER INFORMATION Employer Mailing Address
Enter text: The named insured's mailing address line one.
EMPLOYER INFORMATION City
Enter text: The named insured's mailing address city name.
EMPLOYER INFORMATION State
Enter code: The named insured's mailing address state or province code.
EMPLOYER INFORMATION Zip
Enter code: The named insured's mailing address postal code.
EMPLOYER INFORMATION Employer FEIN
Enter identifier: The tax identifier of the named insured.
EMPLOYER INFORMATION Insured Employer
Name of Workers Compensation
Insurance Company or Self-
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
EMPLOYER INFORMATION Insurer FEIN
Enter identifier: The tax identifier of the insurer.
EMPLOYER INFORMATION Insured Employer
Name and Address of Third Party
Administrator (TPA) used by the
Insurance Company or Self-
Enter text: The name of the carrier, third party administrator, state fund, or self-insured
responsible for administering the claim.
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Section Name
Field Name
Field and/or Section Description
EMPLOYER INFORMATION
Enter text: The first address line of the claim administrator's mailing address.
EMPLOYER INFORMATION
Enter text: The city of the claim administrator's mailing address.
EMPLOYER INFORMATION
Enter code: The state or province code of the claim administrator's mailing address.
EMPLOYER INFORMATION
Enter code: The postal code of the claim administrator's mailing address.
EMPLOYER INFORMATION TPA FEIN
Enter identifier: The tax identifier of the claim administrator.
WAGE INFORMATION
Wage at Time of Injury
Enter amount: The employee's average wage amount.
WAGE INFORMATION
Specify per hr., wk., mo., yr., etc.
Enter code: Indicates the frequency at which the average wage amount is paid.
WAGE INFORMATION
Is worker paid overtime ? Yes
Check the box (if applicable): Indicates the employee receives overtime pay.
WAGE INFORMATION
Is worker paid overtime ? No
Check the box (if applicable): Indicates the employee does not receive overtime pay.
WAGE INFORMATION
If Yes, after how many hours per
week.
Enter number: The number of hours an employee must work per week prior to being paid
for overtime.
WAGE INFORMATION
Check boxes if employee received:
Meals
Check the box (if applicable): Indicates the employee received meals in addition to their
wages.
WAGE INFORMATION
Number of Meals per Week
Enter number: The number of meals per week the employee received.
WAGE INFORMATION
Check boxes if employee received:
Room
Check the box (if applicable): Indicates the employee received a room in addition to their
wages.
WAGE INFORMATION
Number of Days per Week
Enter number: The number of days per week the employee received a room..
WAGE INFORMATION
Check boxes if employee received:
Tips
Check the box (if applicable): Indicates the employee received tips in addition to their
wages.
WAGE INFORMATION
Average Weekly Amount
Enter amount: The average weekly amount of tips the employee received.
WAGE INFORMATION
Employee's Work Schedule when
injured: Start Time
Enter time: The employee's scheduled start time when injured.
WAGE INFORMATION
Employee's Work Schedule when
injured: Hours per Day
Enter number: The number of hours per day the employee was working when injured.
WAGE INFORMATION
Employee's Work Schedule when
injured: Hours per Week
Enter number: The number of hours per week the employee was working when injured.
WAGE INFORMATION
Employee's Work Schedule when
injured: Days per Week
Enter number: The number of days per week the employee was working when injured.
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Section Name
Field Name
Field and/or Section Description
WAGE INFORMATION
Employee's Normal Full-Time
Schedule for Injured's Work: Start
Time
Enter time: The employee's normal full time scheduled start time.
WAGE INFORMATION
Employee's Normal Full-Time
Schedule for Injured's Work:
Hours per Day
Enter number: The number of hours per day the employee works when on their normal full-
time schedule.
WAGE INFORMATION
Employee's Normal Full-Time
Schedule for Injured's Work:
Hours per Week
Enter number: The number of hours per week the employee works when on their normal
full-time schedule.
WAGE INFORMATION
Employee's Normal Full-Time
Schedule for Injured's Work: Days
per Week
Enter number: The number of days per week the employee works when on their normal
full-time schedule.
WAGE INFORMATION
Number of Weeks
Enter number: The number of weeks works in the 52 weeks prior to the injury/illness
occurring.
WAGE INFORMATION
Gross Amount Excluding Tips
Enter amount: The gross wages amount, excluding tips, in the 52 weeks prior to the
injury/illness occurring.
WAGE INFORMATION
If Piece Work Number of Hours
Excluding Over Time
Enter number: The number of pieces per hour, excluding overtime, in the 52 weeks prior
to the injury/illness occurring.
WAGE INFORMATION
Schedule Hours per Week
Enter number: The number of hours scheduled per week for a part-time employee.
WAGE INFORMATION
Are there other part-time workers
doing the same work with the
same schedule? Yes
Check the box (if applicable): Indicates there are other part-time workers doing the same
work with the same schedule.
WAGE INFORMATION
Are there other part-time workers
doing the same work with the
same schedule? No
Check the box (if applicable): Indicates there are not other part-time workers doing the
same work with the same schedule.
WAGE INFORMATION
Number of part-time employees
doing the same kind of work.
Enter number: The number of other part-time workers doing the same work with the same
schedule.
WAGE INFORMATION
Number of full-time employees
doing the same kind of work.
Enter number: The number of full-time employees doing the same type of work.
INJURY INFORMATION
Date of Injury Month
Enter number: The month the loss occurred.
INJURY INFORMATION
Date of Injury Day
Enter number: The day of the month the loss occurred.
INJURY INFORMATION
Date of Injury Year
Enter year: The year the loss occurred.
INJURY INFORMATION
Time of injury AM
Enter time: The approximate time that the loss occurred.
INJURY INFORMATION
Time of injury PM
Enter time: The approximate time that the loss occurred.
INJURY INFORMATION
Last Day Worked Month
Enter number: The month in which the employee last worked.
INJURY INFORMATION
Last Day Worked Day
Enter number: The day of the month the employee last worked.
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Section Name
Field Name
Field and/or Section Description
INJURY INFORMATION
Last Day Worked Year
Enter year: The year the employee last worked.
INJURY INFORMATION
Date Employer Notified Month
Enter number: The month the employer was notified or became aware of the employee's
work related disability/incapacity.
INJURY INFORMATION
Date Employer Notified Day
Enter number: The day of the month the employer was notified or became aware of the
employee's work related disability/incapacity.
INJURY INFORMATION
Date Employer Notified Year
Enter year: The year the employer was notified or became aware of the employee's work
related disability/incapacity.
INJURY INFORMATION
Date Returned to Work (checkbox)
Check the box (if applicable): Indicates the return to work date is the actual date the
employee returned to work.
INJURY INFORMATION
Estimated Date of Return
(checkbox)
Check the box (if applicable): Indicates the return to work date is the estimated date the
employee will return to work.
INJURY INFORMATION
Month
Enter number: The day the claimant returned/will return to work.
INJURY INFORMATION
Day
Enter number: The month the claimant returned/will return to work.
INJURY INFORMATION
Year
Enter year: The year the claimant returned/will return to work.
INJURY INFORMATION
Was this a lost time or other
compensable injury? Yes
Check the box (if applicable): Indicates this is a lost time or compensable injury.
INJURY INFORMATION
Was this a lost time or other
compensable injury? No
Check the box (if applicable): Indicates this is not a lost time or compensable injury.
INJURY INFORMATION
Did injury occur as a result of:
Substance Abuse
Check the box (if applicable): Indicates the cause of loss is a result of substance abuse.
INJURY INFORMATION
Did injury occur as a result of:
Failure to Use Safety Devices
Check the box (if applicable): Indicates the cause of loss is a result of the failure to use
safety devices.
INJURY INFORMATION
Did injury occur as a result of:
Failure to Obey Rules
Check the box (if applicable): Indicates the cause of loss is a result of the failure to obey
rules.
INJURY INFORMATION
Did injury cause death? Yes
Check the box (if applicable): Indicates the incident resulted in a fatality.
INJURY INFORMATION
Did injury cause death? No
Check the box (if applicable): Indicates the incident did not result in a fatality.
INJURY INFORMATION
Date of Death Month
Enter number: The month of the employee's date of death.
INJURY INFORMATION
Date of Death Day
Enter number: The day of the month of the employee's date of death.
INJURY INFORMATION
Date of Death Year
Enter year: The year of the employee's date of death.
INJURY INFORMATION
Name of Closest Dependent of
Deceased if injury caused death
Enter text: The full name of the employee's closest dependent.
INJURY INFORMATION
Relationship
Enter code: The relationship of the dependent to the employee. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
INJURY INFORMATION
Address Line 1
Enter text: The employee's closest dependent's first address line.
INJURY INFORMATION
Address Line 2
Enter text: The employee's closest dependent's second address line.
INJURY INFORMATION
Address Line 3
Enter text: The employee's closest dependent's city name.
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Section Name
Field Name
Field and/or Section Description
INJURY INFORMATION
Enter code: The employee's closest dependent's state or province code.
INJURY INFORMATION
Enter code: The employee's closest dependent's postal code.
INJURY INFORMATION
Name of witness
Enter text: The name of a person that was a witness to the incident.
INJURY INFORMATION
Name of Treating Practitioner and
Hospital
Enter text: The full name of the physician.
INJURY INFORMATION
Enter text: The name of the hospital.
INJURY INFORMATION
Address of Treating Practitioner
and Hospital Line 1
Enter text: The physician's first mailing address line.
INJURY INFORMATION
Enter text: The hospital's mailing address line one.
INJURY INFORMATION
Address of Treating Practitioner
and Hospital Line 2
Enter text: The physician's second mailing address line.
INJURY INFORMATION
Enter text: The hospital's mailing address line two.
INJURY INFORMATION
Address of Treating Practitioner
and Hospital Line 3
Enter text: The physician's mailing address city name.
INJURY INFORMATION
Enter code: The physician's mailing address state or province code.
INJURY INFORMATION
Enter code: The physician's mailing address postal code.
INJURY INFORMATION
Enter text: The hospital's mailing address city.
INJURY INFORMATION
Enter text: The hospital's mailing address state or province code.
INJURY INFORMATION
Enter text: The hospital's mailing address line postal code.
INJURY INFORMATION
Injury Description
Enter text: The description of 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, (e.g., Worker stepped back to inspect work
and slipped on some scrap metal. As worker fell, worker brushed against hot metal).
INJURY INFORMATION
Report Prepared by
Enter text: The name of the individual that prepared the claim form.
INJURY INFORMATION
Work Phone No.
Enter number: The phone number of the individual that prepared the claim form.
INJURY INFORMATION
Position
Enter text: The title of the individual that prepared the claim form.
INJURY INFORMATION
Date Signed
Enter date: The date the preparer signed the form.
REMARKS
Remarks
Enter text: The workers compensation first report or injury/illness general remarks.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
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