FIRST REPORT OF INJURY
AKA FROI, Form 2. Submit when Injured Worker receives medical treatment away from the jobsite, or misses time past their normal shift. You can also submit "incident only" claims when an incident occurs but no medical treatment is sought. These "IO" claims do not count on your loss history and are for informational purposes only unless medical treatment is obtained at a later date. Section to mark the claim as "Incident Only" is under "Injury Type" on Page 3.
Employee Information
Employee Name
*
First Name
Middle Name
Last Name
Last 5 Digits SSN
*
Employee Gender
*
Please Select
Male
Female
Other/Unspecified
Employee Date of Hire
*
-
Month
-
Day
Year
Date
Employee Date of Birth
*
-
Month
-
Day
Year
Date
Employee Email
*
example@example.com
Employee Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee Occupation
*
Employee Normal Work Shift
Employee Employment Status
Full Time, Part Time etc.
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Employer Information
Name of Employer
*
Federal ID Number
*
Organization/Location/Department where injury occurred
Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Provider
*
Please Select
Self-Insured
OSAG
OMAG
CALM
OESA
Unknown
Own Risk # or Policy Number, if known
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Injury Information
Date of Injury
*
-
Month
-
Day
Year
Date
Date Employer Notified of Injury
*
-
Month
-
Day
Year
Date
Time of Injury
Hour Minutes
AM
PM
AM/PM Option
Time Workday Began
Hour Minutes
AM
PM
AM/PM Option
Date Employee Last Worked
-
Month
-
Day
Year
If claim is Lost Time
Has Employee Returned to Work
Please Select
Yes
No
N/A
Body Part Injured
*
Include Left/Right/Both if applicable. Can list multiple body parts
Nature of Injury
*
Sprain, Strain, Fracture, e.g.
Cause of Injury
*
Fall, slip, lifting e.g.
Injury Resulted From
*
Please Select
Single Incident
Cumulative Trauma
Occupational Disease
Injury Type
*
Please Select
Medical Only
Lost Time
Incident Only (no injury; for info only)
Death
Was there video of the accident?
Please Select
Yes
No
N/A
Injury Description Narrative
*
Describe how the injury occurred, including any objects or job duties involved in the injury
Zip Code Where Injury Occurred
*
Location Where Injury Occurred
Parking lot, classroom, e.g
Did Injury Occur on Employer's Premises?
Please Select
Yes
No
N/A
Were Other Workers Injured In This Event?
Please Select
Yes
No
N/A
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Medical Treatment Information
Treating Physician
Name of Hospital/Urgent Care Clinic
Hospital/Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Was The Employee Hospitalized Overnight?
Please Select
Yes
No
N/A
Was The Employee Treated In An Emergency Room?
Please Select
Yes
No
N/A
If Employee Has A Return Appointment, Enter Date
-
Month
-
Day
Year
Date
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Other Information
Were the Employee's Wages Paid In Full For The Day?
Please Select
Yes
No
N/A
If Lost Time Beyond First Day, Was Salary Continued?
Please Select
Yes
No
N/A
Police/Fire Union Contracts, e.g.
Estimated Average Weekly Wage
*
Is Employee on Medicare
Please Select
Yes
No
N/A
Is Employee on SSDI
Please Select
Yes
No
N/A
Does the Employee Have a Child Support Lien?
Please Select
Yes
No
N/A
Is There a Potential For Subrogation?
Please Select
Yes
No
N/A
If Potential Subrogation Exists, Please Describe
Third Party at fault auto accident, defective product, independent contractor at work contributed to accident, e.g.
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Terms and Agreements
Signature
*
Email Address of Sender
*
You will receive an email copy of your submission
Secondary Email Address
Enter if you wish for someone else in your Organization should receive a copy of this submission
File Upload
Browse Files
Drag and drop files here
Choose a file
Attach any supplemental Forms, like Supervisor incident report, Employee Incident Report, Medical Authorization Form, e.g. ***Not Mandatory, can be submitted to Claims Adjuster later
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Please verify that you are human
*
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