Ohio > Workers Comp > Injured Workers
First Report Of An Injury Occupational Disease Or Death FROI-1 - Ohio
| First Report Of An Injury Occupational Disease Or Death Form. This is a Ohio form and can be used in Injured Workers Workers Comp . |
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First Report of an Injury, Occupational Disease or Death This form can be completed and submitted online at ohiobwc.com Report your injury by completing all three sections of this form 1 Complete as much of all three sections of this form as possible to reduce the time necessary in determining the claim. If this form is completed by the injured worker at the irst visit to a medical provider, the injured worker may give the FROI to the provider to complete the treatment information section. The provider can then submit the FROI to the MCO. your employer or your employer's managed care organization (MCO). 3 If you do not know your employer's MCO, contact BWC at 1-800-OHIOBWC and follow the prompts, or use the MCO on BWC's Web site at ohiobwc.com. If you are unable to determine your MCO, mail or fax this form to the BWC customer service ofice closest to your home. For information on your local customer service ofice, please visit ohiobwc.com, or call 1-800-OHIOBWC. 4 2 Deliver, mail or fax the completed document to Injured workers employed by a self-insuring employer · Complete this form and give to your employer. · Your employer should be able to tell you if he or she is a self-insuring employer. · If your employer is self-insuring and you ile this information with BWC, processing delays may occur. For assistance in completing this form, call your BWC customer service office Monday through Friday, 8 a.m. 5 p.m. Cambridge 61501 Southgate Road Cambridge, OH 43725 Phone: 740-435-4200 Fax: 866-281-9351 Canton 400 Third St., SE Canton, OH 44702-1102 Phone: 330-438-0638 Toll free: 800-713-0991 Fax: 866-281-9352 Cleveland 615 Superior Ave. W. Cleveland, OH 44113-1889 Phone: 216-787-3050 Toll free: 800-821-7075 Fax: 866-336-8345 Columbus 30 W. Spring St. Columbus, OH 43215-2256 Phone: 614-728-5416 Fax: 866-336-8352 Dayton 3401 Park Center Drive Dayton, OH 45413-0910 Phone: 937-264-5000 Fax: 866-281-9356 Garfield Heights 4800 E. 131 St., Suite A Garfield Heights, OH 44105 Phone: 216-584-0100 Toll free: 800-224-6446 Fax: 866-457-0590 Governor's Hill 8650 Governor's Hill Drive Cincinnati, OH 45249 Phone: 513-583-4400 Fax: 866-281-9357 Hamilton 1 Renaissance Center 345 High St. Hamilton, OH 45011 Phone: 513-785-4500 Fax: 866-336-8343 Lima 2025 E. Fourth St. Lima, OH 45804-4101 Phone: 419-227-3127 Toll free: 888-419-3127 Fax: 866-336-8346 Logan P.O. Box 630 1225 W. Hunter St. Logan, OH 43138-0630 Phone: 740-385-5607 Toll free: 800-385-5607 Fax: 866-336-8348 Mansfield 240 Tappan Drive, N. Mansfield, OH 44906-8051 Phone: 419-747-4090 Fax: 866-336-8350 Portsmouth 1005 Fourth St. Portsmouth, OH 45662-1307 Phone: 740-353-2187 Fax: 866-336-8353 Toledo P.O. Box 794 1 Government Center, Suite 1136 Toledo, OH 43697-0794 Phone: 419-245-2700 Fax: 866-457-0594 Youngstown 242 Federal Plaza, W., Suite 200 Youngstown, OH 44501-1877 Phone: 330-797-5500 Toll free: 800-551-6446 Fax: 866-457-0596 American LegalNet, Inc. www.FormsWorkFlow.com Injured worker and injury/disease/death info. Completion instructions (continued) Last name, first name, middle initial Home mailing address City 1 State 9-digit ZIP code Wage rate $________________ Per: Bureau of Workers' Compensation? YES 3 Hour Year Month Week Other _________________ Marital status Single Married Male Female Divorced Separated Country if different from USA Widowed What days of the week do you usually work? Sun Mon Tues Wed Thur 4 Sex Social Security number Date of birth Number of dependents Department name 2 6 Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio NO If yes, please explain. 5 Regular work hours Fri Sat From ____ To ____ 4 Occupation or job title Employer name 7 Mailing address (number and street, city or town, state, ZIP code and county) Location, if different from mailing address Was place of accident or exposure on employer's premises? Yes No If no, give accident location, street address, city, state and ZIP code. Date returned to work Date of injury/disease If fatal, give date of death Time employee began Date last worked Time of injury 9 8 __________ a.m. p.m. work ______ a.m. p.m. 10 Date hired State where hired Date employer notified State where supervised 11 Description of accident (Describe the sequence of events that directly injured the employee, or caused the disease or death) PLE SAM 12 13 14 Type of injury/disease and part(s) of body affected (for example: sprain of lower left back, etc.) 15 Beneit application release of information I am applying for a claim under the Ohio Bureau of Workers' Compensation Act for work-related injuries that I did not inflict. I affirm that I elect to receive compensation and benefits under the Ohio workers' compensation laws for my claim, and I waive and release my right to file for and receive compensation and benefits under the laws of any other state for this claim. I request payment for compensation and/or medical benefits as allowable, and authorize direct payment to my medical providers. I permit and authorize any provider who attends, treats or examines me, and the Ohio Rehabilitation Services Commission (where relevant) to release medical, psychological, psychiatric, vocational or social information that is casually or historically related to my physical or mental injuries relevant to issues necessary for the administration of my claim to BWC, the Industrial Commission of Ohio, the employer in this claim, the employer's BWC managed care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim. Proper administration of the present claim may require BWC to share claims information with the employers of record (or their authorized representatives) and/or my authorized representative for any and all such previous or future claims. The released claims information may include any record maintained in my claim files. Date Injured worker signature Telephone number Work number E-mail address () () 16 1 Home address: Enter the home address where the injured worker lives. Include the apartment number, if applicable. · If the post ofice does not deliver mail to the home address, list the mailing address instead of the home address. 9 Date last worked: Enter the last day worked as a result of this injury, occupational disease or death. 10 Date returned to work: Enter the date the injured worker returned to work after the injury or occupational disease. 11 State where hire
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