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OhioBWC - Common - Form: (FROI) - Introduction
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First Report of an Injury, Occupational Disease or Death
(FROI)
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| Introduction |
In compliance with the Federal Trade Commission Children's Online Privacy Protection
Rule, BWC will not collect any information from any person under the age of 13. Please do
not submit any information to BWC if you are under the age of 13. Contact BWC with any
questions.
The FROI meets Occupational Safety and Health Administration (OSHA) requirements and may
be used in place of the OSHA 301 to report recordable injuries and illnesses to the
federal government.
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Additional information
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Authorization to Release Medical Information
Claim Status Information Description
ICD-9 Coding Description
Appeal Information Description
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Required information
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- Injured Worker Name
- Injured Worker SSN
- Injured Worker Mailing Address
- Injured Worker Home or Work Phone Number
- Date of Birth
- Date of Injury/Disease
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- Gender
- Occupation or Job Title
- Description of Accident
- Type of Injury/Disease and Part(s) of Body Affected
- Employer Policy Number (look-up function provided)
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- Injured Worker Name
- Injured Worker SSN
- Injured Worker Mailing Address
- Injured Worker Home or Work Phone Number
- Date of Birth
- Date of Injury/Disease
- Gender
- Occupation or Job Title
- Description of Accident
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- Type of Injury/Disease and Part(s) of Body Affected
- Employer Policy Number (look-up function provided)
- Place of Accident or Exposure on Employer’s Premises
- Date Hired
- Date Employer Notified
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- Injured Worker Name
- Injured Worker SSN
- Injured Worker Mailing Address
- Injured Worker Home or Work Phone Number
- Date of Birth
- Date of Injury/Disease
- Causality Indicator
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- Gender
- Occupation or Job Title
- Description of Accident
- Type of Injury/Disease and Part(s) of Body Affected
- Employer Policy Number (look-up function provided)
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| Complete the forms |
The free Adobe Reader
software is required to display and print the application.
Do you have all the required information at hand? If so, you can complete the online form.
When completing the online form, please use the previous and next
buttons located at the bottom of the page to navigate
through the form.
If you are an employer or a medical provider and you either have or want to establish an e-account (user ID
and password) with BWC, please click
log on. Logging on allows us to automatically fill in important information
on the FROI that we have on file for you, such as your name and address, and employers who log on can certify
the claim.
Employer
Medical Provider
Complete FROI
Are you missing any required information? If so, you may return here
at a later time when you have all the information you need, and complete
this online form. You also can print a blank copy of the form to complete by
hand, and either mail or fax it to the employer's managed care organization or BWC.
Print a blank form.
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