ACORD 4 — Workers Compensation - First Report of Injury

Edition 2008/10 · PDF format

Required form for reporting workplace injuries or illnesses. Collects employee details, injury description, medical treatment information, and wage data for workers comp claims.

What is ACORD 4?

ACORD 4 (Workers Compensation First Report of Injury, often called the FROI) is the standard form for reporting a workplace injury or occupational illness to the workers compensation carrier and, in many states, to the state workers compensation bureau.

Most states require the FROI to be filed within a specific number of days after the injury is reported by the employee, commonly 7–10 days. Late reporting can trigger penalties from the state and may delay benefits to the injured worker.

Who needs this form

Employers reporting workplace injuries or illnesses. The form is filed with the carrier and (in most states) with the state workers compensation bureau.

When to use it

File immediately after an injury is reported, ideally within 24 hours and certainly within state-required deadlines.

Key Fields on ACORD 4

The information the form captures, in the order it typically appears:

Employer name, FEIN, mailing address
Carrier and policy number
Employee name, DOB, address, occupation, hire date
Wage information (rate, hours per week)
Date and time of injury
Location of injury
Description of how the injury occurred
Body part(s) affected and nature of injury
Medical treatment (initial provider, hospital)
Witnesses
Whether employee returned to work

Common Mistakes

Recurring errors that delay processing or expose brokers to E&O claims:

Late reporting

States impose penalties for late FROI filings. File within state-required timeframes, usually 7–10 days from notice of injury.

Vague injury description

Describe what the employee was doing, exactly how the injury occurred, and what body parts were affected. Vague descriptions slow the adjuster's investigation and benefit determination.

Wrong wage data

Wage data drives indemnity benefit calculations. Use accurate weekly wages including overtime and bonuses where applicable.

Frequently Asked Questions

Is the FROI the same in every state?

No. While ACORD 4 is the universal national form, many states have their own state-specific FROI variants that must be used instead of (or in addition to) ACORD 4.

Should I file an FROI for a first-aid-only injury?

Depends on state requirements. Some states only require reporting injuries that involve lost time or medical treatment beyond first aid. When in doubt, report. Penalties for over-reporting are zero.

Related ACORD Forms

ACORD 130