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 Information (Injured Worker)
- Section 2 - Treatment Information (Provider)
- Section 3 - Employer Information (Employer)
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.
Fax to: 1-800-869-1871.
Please visit the BWC website at https://www.ohiobwc.com for additional information.
Injured Worker Information - To be completed by the injured worker.
- LAST NAME, FIRST NAME, MIDDLE INITIAL: Enter injured worker’s last name, first name, middle initial.
- SOCIAL SECURITY NUMBER: Enter the 9 digit Social Security number of the injured worker.
- MARITAL STATUS: Enter marital status of injured worker.
- DATE OF BIRTH: Enter date of birth of injured worker
- HOME ADDRESS: Enter home address, including any apartment number, of injured worker for mailings.
- SEX: Enter male or female
- NUMBER OF DEPENDENTS: Enter number of dependents claimed by injured worker.
- CITY, STATE 9 DIGIT ZIP CODE: Enter the injured worker’s city, state, zip code.
- COUNTRY IF DIFFERENT THAN USA: Enter the appropriate country if not USA.
- DEPARTMENT: Enter department name in which the injured worker works.
- WAGE RATE: Enter the wage rate and frequency of the injured worker.
- WHAT DAYS OF THE WEEK DO YOU USUALLY WORK: Check the appropriate days of the week that are normally worked.
- REGULAR WORK HOURS: Enter regular work hours of the injured worker.
- 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.
- OCCUPATIONAL OR JOB TITLE: Enter injured worker’s occupation or job title.
- EMPLOYER NAME: Enter the name of the employer of the injured worker.
- MAILING ADDRESS: Enter the address of the employer
- LOCATION, IF DIFFERENT FROM MAILING ADDRESS: Enter the location of the injury if it was someplace other than the employer’s address listed above.
- WAS PLACE OF ACCIDENT OR EXPOSURE ON EMPLOYER’S PREMISES? Answer yes or no. If yes, give complete address of location of accident
- DATE OF INJURY/DISEASE: Enter date of injury or disease
- TIME OF INJURY: Enter time of injury and indicate either AM or PM.
- IF FATAL, GIVE DATE OF DEATH: Enter date of death, if applicable
- TIME EMPLOYEE BEGAN WORK: Enter the time employee began work on the day of injury. Indicate Am or PM.
- DATE LAST WORKED: Enter date last worked.
- DATE RETURNED TO WORK: Enter return to work date, if applicable.
- DATE HIRED: Enter date the injured worker was hired
- STATE WHERE HIRED: Enter the state where the injured worker was hired.
- DATE EMPLOYER WAS NOTIFIED: Enter the date the employer was notified of the injury.
- ACCIDENT LOCATION: Enter street address of accident location
- DATE HIRED: Enter date hired
- STATE WHERE HIRED: Enter state hired.
- DATE EMPLOYER NOTIFIED: Enter date employer notified
- CITY: Enter accident city
- STATE: Enter accident state
- 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.)
- TYPE OF INJURY: Enter type of injury and part(s) of body affected (ie sprain of left shoulder,etc).
- BENEFIT APPLICATION/MEDICAL RELEASE: Signature of injured worker, with the date – include the injured workers home and work phone numbers.
Treatment Information - To be completed by the provider
- PHYSICIAN/HEALTH CARE PROVIDER NAME: Enter name of provider.
- TELEPHONE NUMBER: Enter telephone number of the provider
- FAX NUMBER: Enter fax number of the provider
- INITIAL TREATMENT DATE: Enter first date of service with provider
- STREET ADDRESS: Enter the physical address of the provider
- CITY: Enter the providers city
- STATE: Enter the providers state
- 9 DIGIT ZIP CODE: Enter the zip code (zip + 4 if possible)
- DIAGNOSIS (ES): Provider enter all diagnosis related treated for the workers’ compensation injury.
- 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.
- 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).
- PROVIDER SIGNATURE/DATE: Provider signature
- BWC PROVIDER NUMBER: Provider enters 11-didit BWC provider number.
- DATE: Provider enters date completed.
Employer Information - To be completed by the employer.
- EMPLOYER POLICY NUMBER: Employer enter your risk number
- “CHECK IF”: Mark appropriate box if either apply
- TELEPHONE NUMBER: Enter telephone number of the employer
- FAX NUMBER: Enter the fax number of the employer
- EMAIL: Enter the email address for the employer
- FEDERAL ID NUMBER: Enter employers Federal ID number
- MANUAL NUMBER: Enter the manual number for the job the injured worker performs
- WAS THE EMPLOYEE TREATED IN THE EMERGENCY: Enter yes or no (which ever applies)
- WAS THE EMPLOYEE HOSPITALIZED OVERNIGHT: Enter yes or no.
- IF TREATMENT WAS GIVEN AWAY FROM WORKSITE, PROVIDER FACILITY NAME, STREET ADDRESS, CITY , STATE AND ZIPCODE.
- CERTIFICATION/REJECTION INFORMATION: Check the appropriate box. If the certification is rejection, document a reason on the following lines.
- EMPLOYER SIGNATURE, TITLE, DATE AND TELEPHONE NUMBER: Employer’s representative signature, name, title and date
- OSHA CASE NUMBER: If available