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OhioBWC - Common - Form:  (FROI) - Introduction

First Report of an Injury, Occupational Disease or Death
(FROI)
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.


Additional information

Authorization to Release Medical Information
Claim Status Information Description
ICD-9 Coding Description
Appeal Information Description

Required information
If you are an injured worker
  • 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)
If you are an employer
  • 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)

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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