Enlarge image
online form
First Report of an Injury,
Occupational Disease or Death (FROI)
Instructions
To expedite your claim, you can complete and submit this form online at www.bwc.ohio.gov.
• If submitting the hard copy form, complete as much of this form as possible to reduce the time necessary
for BWC to determine the claim.
• If you complete this form at your first visit to a medical provider, the provider should complete the treatment
information section. The provider can then submit the FROI to the managed care organization (MCO).
• You should also report this injury to your employer.
Where do I file the hard copy FROI?
For injured workers whose employer is self-insured: Send the form to your self-insuring employer. If you are not
sure if your employer is self-insured, ask your employer.
For all other injured workers: Fax the form to 1-866-336-8352, or send it to your local BWC customer service office.
1 Home address: Address where you live, including the 9 Date last worked: Enter the last day worked as a result of
apartment number, if applicable. this injury, occupational disease.
• If the post office does not deliver mail to the home
address, list the mailing address. 10 Date returned to work: Enter the date you returned to work
after the injury or occupational disease.
2 Department name: Enter the department where you
normally report for work. 11 State where hired: Enter the state where the employer
3 Wage rate: Enter your rate of pay, then select how often listed on this application hired you.
you receive it. (If the pay rate reported is not hourly, report 12 Date employer notified: Enter the date that you notified
the gross amount.) the employer of the injury, occupational disease or death.
• If you will miss eight or more days of work, BWC
needs wage information for the 52 weeks prior to the 13 State where supervised: Enter the state where the employer
date of injury. listed on the application supervised you.
4 What days of the week do you usually work? What are your 14 Description of accident: Describe in detail the events that
regular work hours: Enter the days and hours you normally caused the injury, occupational disease or death.
work.
• If the days worked vary from week to week, list the 15 Type of injury/disease and part of body affected: Describe
number of hours worked in an average week. the nature of the injury, occupational disease or death.
5 Wages: If you received wages during disability, please explain. Indicate the part(s) of body injured, affected or that caused
the death.
6 Occupation or job title: Enter the type of occupation or job
title at the time of injury, occupational disease or death. Examples:
7 Employer name: Enter the name of your employer at the • Laceration of first toe, left foot;
Injured worker and injury/disease/death info. time of the injury, occupational disease or death. • Sprain of lower right back; etc.
8 Date of injury/disease: Enter the date you were injured, or 16 Injured worker signature (injured workers only): Please
if you contracted an occupational disease, determine which read the Benefit application/Medical release information
of the following happened most recently: before signing and dating this form.
• The occupational disease was diagnosed by a
medical provider;
• The first medical treatment;
• The injured worker first quit work, due to the
occupational disease.
Enter this as the date of occupational disease.
For death claims, enter the injured worker date of death.
