Electronic Data Interchange First Report Of Injury {LIBC-90}

bureau of workers' compensation ElECtronIC data IntErChangE First report of Injury Jurisdictional Claim number: (e.g.ClM-2012021312345) date transaction Submitted to BWC: May 8 2012 01:30 PM transaction title: (e.g. FroI) transaction type: (e.g. denial 04) Employee Information First Name: Last Name: Employee ID: Date of Birth: Number of Dependents: Mailing City: Mailing State Code: Mailing Postal Code: Gender Code: Mailing Primary Address: Mailing Secondary Address: Mailing Country Code: Phone Number: Date Of Hire: Occupation Description: Middle Name: Last Name Suffix: ID Type: Date of Death: Employee Marital Status Code: Claim Information Jurisdiction Claim Number: Initial Date Disability Began: Type of Loss: Death Result of Injury Code: Claim Status Code: Late Reason Code: Accident Site County/Parish: Initial Return to Work Date: Initial Date Last Day Worked: Employment Status Code: Employer Paid Salary in Lieu of Compensation Indicator: Date Employer Had Knowledge of Date of Disability: Return to Work Type Code: Jurisdiction: Claim Type Code: Injury Information Date of Injury: Nature of Injury Code: Time of Injury: Claim Transaction Details-FROI (LIBC-344) LIBC-90 REV 05-13 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com Injury Information Part of Body Injury Code: Cause of Injury Code: Accident/Injury Description Narrative: denial Information Full Denial Reason Code: Denial Reason Narrative: Insurer Information Insured Report Number: Insurer FEIN: Insured Name: Insured Type Code: Insurer Name: Insured FEIN: Claim administrator Information Claim Administrator Name: Claim Administrator FEIN: Claim Administrator Postal Code: Claim Administrator Claim Number: Claim Administrator City: Claim Administrator State Code: Claim Administrator Information/Attention Line: Claim Administrator Primary Address: Claim Administrator Secondary Address: Claim Administrator County Code: Employer Information Name: Physical Primary Address: Secondary Address: Physical City: Physical Postal Code: Physical Country Code: Employer FEIN: Claim Transaction Details-FROI (LIBC-344) LIBC-90 REV 05-13 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com Employer Information Contact Name: Mailing Secondary Address: Mailing City: Mailing Postal Code: Mailing State Code: Mailing Country Code: Mailing Information/Attention Line: Policy Number Identifier: Contact Business Phone: Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program Claim Transaction Details-FROI (LIBC-344) LIBC-90 REV 05-13 (Page 3) American LegalNet, Inc. www.FormsWorkFlow.com