OhioBWC - Common - Form:  (FROI) - Introduction

First Report of an Injury, Occupational Disease or Death
(FROI)
Introduction
Injured workers, employers or medical providers use this form to initiate a workers' compensation claim. Whoever completes the form should provide as much detailed information as possible.

You'll see below a list of required information to complete the form depending on who you are. If you have all the required information on hand, simply click on the appropriate link to begin.

Employer - business or authorized rep for the business Medical Provider - physician, medical facility or another medical provider Complete FROI - Injured worker, authorized rep for injured worker or other

Note: If you're an employer or medical provider with a BWC e-account (user ID and password), log on first. This allows us to automatically fill in important information we already have on file for you, such as your name and address. And employers who log on can certify the claim.



Required information
If you are an injured worker or injured worker authorized rep

  • Injured worker name
  • Injured worker SSN
  • Injured worker mailing address
  • Injured worker home or work phone number
  • Date of birth
  • Date of injury/disease
  • Occupation or job title
  • Gender
  • Description of accident
  • Type of injury/disease and Part(s) of body affected
  • Employer policy number (look-up function provided)
If you are an employer or employer authorized rep

  • 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
  • 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
If you are a provider

  • 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
  • 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)



Additional information
Authorization to Release Medical Information (C-101)
ICD coding description - Diagnosis codes
Claim status definitions
Appeal information - What happens when a party disagrees with decision?

IMPORTANT
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 my be used in place of the OSHA 301 to report recordable injuries and illnesses to the federal government.