Instructions for Completing a FROI

The FROI-1 is the First Report of Injury.  It is a BWC form that is required to begin the process of filing a claim.  The form contains 3 sections.

Section 1 - Injured Worker and Injury /Diseases /Death Information

Section 2 - Treatment Information

Section 3 - Employer Information

The FROI-1 should be filled out as completely as possible and faxed to 3-hab within 24 hours of the first date of service.  Note that the first section is to be filled out by the injured worker, the second is to be completed by the provider, and the third section by the employer. Fax 1-800-869-1871.  You can visit BWC website at www,ohiobwc.com for additional information.

 

SECTION 1

PART 1 Injured worker and injury/disease/death- This section should be completed by the injured worker following the boxes from left to right.

  1. LAST NAME, FIRST NAME, MIDDLE INITIAL: Enter injured worker’s last name, first name, middle initial. 
  2. SOCIAL SECURITY NUMBER: Enter the 9 digit Social Security number of the injured worker. 
  3. MARITAL STATUS: Enter marital status of injured worker. 
  4. DATE OF BIRTH: Enter date of birth of injured worker 
  5. HOME ADDRESS: Enter home address, including any apartment number, of injured worker for mailings. 
  6. SEX: Enter male or female 
  7. NUMNBER OF DEPENDENTS: Enter number of dependents claimed by injured worker. 
  8. CITY, STATE 9 DIGIT ZIP CODE: Enter the injured worker’s city, state, zip code.
  9. COUNTRY IF DIFFERENT THAN USA: Enter the appropriate country if not USA.
  10. DEPARTMENT: Enter department name in which the injured worker works.
  11. WAGE RATE: Enter the wage rate and frequency of the injured worker.
  12. WHAT DAYS OF THE WEEK DO YOU USUALLY WORK: Check the appropriate days of the week that are normally worked.
  13. REGULAR WORK HOURS: Enter regular work hours of the injured worker.
  14. HAVE YOU BEEN OFFERED OR DO YOU EXPECT TO RECEIVE PAYMENT FOR THIS CLAIM FROM ANYONE OTHER THEN THE OHIO BUREAU OF WORKER’S COMPENSATION: Check the appropriate box, and explain if answer if yes.
  15. OCCUPATIONAL OR JOB TITLE: Enter injured worker’s occupation or job title.

SECTION 1 PART 2 Injured worker and injury/disease/death-

This section should be completed by the injured worker following the boxes from left to right.

  1. EMPLOYER NAME: Enter the name of the employer of the injured worker.
  2. MAILING ADDRESS: Enter the address of the employer
  3. LOCATION, IF DIFFERENT FROM MAILING ADDRESS: Enter the location of the injury if it was someplace other than the employer’s address listed above.
  4. WAS PLACE OF ACCIDENT OR EXPOSURE ON EMPLOYER’S PREMISES? Answer yes or no. If yes, give complete address of location of accident
  5. DATE OF INJURY/DISEASE: Enter date of injury or disease
  6. TIME OF INJURY: Enter time of injury and indicate either AM or PM.
  7. IF FATAL, GIVE DATE OF DEATH: Enter date of death, if applicable
  8. TIME EMPLOYEE BEGAN WORK: Enter the time employee began work on the day of injury. Indicate Am or PM.
  9. DATE LAST WORKED: Enter date last worked.
  10. DATE RETURNED TO WORK: Enter return to work date, if applicable.
  11. DATE HIRED: Enter date the injured worker was hired
  12. STATE WHERE HIRED: Enter the state where the injured worker was hired.
  13. DATE EMPLOYER WAS NOTIFIED: Enter the date the employer was notified of the injury.
  14. ACCIDENT LOCATION: Enter street address of accident location
  15. DATE HIRED: Enter date hired
  16. STATE WHERE HIRED: Enter state hired.
  17. DATE EMPLOYER NOTIFIED: Enter date employer notified
  18. CITY: Enter accident city
  19. STATE: Enter accident state
  20. DESCRIPTION OF ACCIDENT: Enter the accident description. The description should be as detailed as possible, including a description of the mechanism if injury (ie I slipped on the wet floor while mopping and fell on my left knee.)
  21. TYPE OF INJURY: Enter type of injury and part(s) of body affected (ie sprain of left shoulder,etc).

SECTON 1 part 3: Injured worker and injury/disease/death – This section should be completed BY THE INJURED WORKER.  Following the boxes from left to right:

BENEFIT APPLICATION/MEDICAL RELEASE: Signature of injured worker, with the date – include the injured workers home and work phone numbers.

 

SECTION 2: TREATMENT – This section should be completed by the provider

SECTION 1 PART 2 Injured worker and injury/disease/death-

This section should be completed by the provider following the boxes from left to right.

  1. 1. PHYSICIAN/HEALTH CARE PROVIDER NAME: Enter name of provider.
  2. 2. TELEPHONE NUMBER: Enter telephone number of the provider 
  3. 3. FAX NUMBER: Enter fax number of the provider 
  4. 4. INITIAL TREATMENT DATE: Enter first date of service with provider 
  5. 5. STREET ADDRESS: Enter the physical address of the provider 
  6. 6. CITY: Enter the providers city 
  7. 7. STATE: Enter the providers state 
  8. 8. 9 DIGIT ZIP CODE: Enter the zip code (zip + 4 if possible) 
  9. 9. DIAGNOSIS (ES): Provider enter all diagnosis related treated for the workers’ compensation injury.
  10. WILL THIS INCIDENT CAUSE THE INJURED WORKER TO MISS 8 OR MORE DAYS OF WORK? Provider is to check this box stating his/her opinion.
  11. IS THIS INJURY CAUSALLY RELATED TO THIS INDUSTRIAL INCIDENT? Provider is to check the appropriate box from information obtained from the injured worker and the exam. (This is not a legal opinion).
  12. PROVIDER SIGNATURE/DATE: Provider signature
  13. BWC PROVIDER NUMBER: Provider enters 11-didit BWC provider number.
  14. DATE: Provider enters date completed.

SECTION 4 EMPLOYMENT – This section should be completed by the employer.

  1. EMPLOYER POLICY NUMBER: Employer enter your risk number
  2. “CHECK IF”: Mark appropriate box if either apply
  3. TELEPHONE NUMBER: Enter telephone number of the employer
  4. FAX NUMBER: Enter the fax number of the employer
  5. EMAIL: Enter the email address for the employer
  6. FEDERAL ID NUMBER: Enter employers Federal ID number
  7. MANUAL NUMBER: Enter the manual number for the job the injured worker performs
  8. WAS THE EMPLOYEE TREATED IN THE EMERGENCY: Enter yes or no (which ever applies)
  9. WAS THE EMPLOYEE HOSPITALIZED OVERNIGHT: Enter yes or no.
  10. IF TREATMENT WAS GIVEN AWAY FROM WORKSITE, PROVIDER FACILITY NAME, STREET ADDRESS, CITY , STATE AND ZIPCODE.
  11. CERTIFICATION/REJECTION INFORMATION: Check the appropriate box. If the certification is rejection, document a reason on the following lines.
  12. EMPLOYER SIGNATURE, TITLE, DATE AND TELEPHONE NUMBER: Employer’s representative signature, name, title and date
  13. OSHA CASE NUMBER: If available