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Iowa Division of Workers’ Compensation – FIRST REPORT OF INJURY OR ILLNESS (FROI) Jurisdiction Code______________ Jurisdiction Claim Number_______________ Claim Administrator Name: Claim Representative Business Insurer Name (if different than claim administrator): Phone Number: Mailing Address, City, State, & Postal Code: Claim Administrator Claim Number: Insurer FEIN: CLAIM ADMIN Claim Administrator FEIN: Claim Type Code: Employer Name: Employer FEIN: Insured Report Number: Employer Type Code: __ Employer (E) Physical Address, City, State, & Postal Code: Mailing Address, City, State, & Postal Code: Industry Code: __ Lessor (L) EMPLOYER Insured Location Number: Employer UI Number: Nature of Business: Employer Contact Name and Business Phone Number: Insured Name (parent company if different than employer): Insured FEIN: Insured Postal Code: Policy/Contract Number: Coverage Effective Date: Self Insurance License/ Certificate Number: POLICY Coverage Expiration Date: Employee Name (First, Middle, Last, & Suffix): Date of Birth: Gender: __ Transgender (T) Tax Filing Status (check one): __ Male (M) __ Non-Binary (X) ____ Single (A) ____ Married/Filing Joint (C) Mailing Address, City, State, & Postal Code: Date of Hire: __ Female (F) Unknown(U)____ ____ Single/Head of Household (B) ____ Married/Filing Separate(D) State of Hire: Educational Level (grade completed): _______ [GED = 12] Marital Status: (check one) Employee ID Number (check one): Email: Employment Status (check one): ___ Unmarried/Single/Divorced (U) ____ Piece Worker ID # ______________________ ___ Married (M) Phone Number (include area code): EMPLOYEE Occupation Description: ____ Volunteer ____ Social Security Number ___ Separated (S) ____ Seasonal ____ Apprenticeship/Full-Time ____ Employment VISA Number Employee’s Authorization to NCCI Classification Code: ____ Apprenticeship/Part-Time ____ Passport Number Release the Following: ____ Regular Employee/Full-Time Department Where Regularly Worked: ____ Part-Time ____ Green Card Medical Records __ yes __ no ____ Other ____ Employee ID Assigned by Jurisdiction Social Security Number __ yes __ no Average Wage $ ___________ (check one): Salary Continued In Lieu of Compensation: ___ yes ___ no Employee Number of Dependents: __________ ___ hourly ___ daily ___ semi-monthly ___ monthly Full Wages Paid for Date of Injury: ___ yes ___ no Employee Number of Exemptions: ___________ (check WAGE ___ bi-weekly ___ annual ___ weekly one) Number of Days Regularly Worked Per Week: _______ Discontinued Fringe Benefits: $_____________ ___ Entitled___ Withholding _____________________ Date of Injury Type of Injury / Illness Code: _____________________ Date Employer Had Knowledge of the Injury Describe the nature of the injury. (ex. amputation, burn, cut, fracture): _____________________ Date Claim Administrator Had Knowledge of the Injury _____________________ Initial Date Last Day Worked _____________________ Initial Return to Work Date (if applicable) Part of Body Affected Code: _____________________ Employee Date of Death (if applicable) Part(s) of body directly affected by the injury or illness. (ex. hand, arm, circulatory system): _____________________ Time of Injury _____________________ Time Employee Began Work Pre-Existing Disability Code: ___ Yes Describe the events that caused the injury. (ex. fell, operating machinery, chemical exposure): ___ No ___ Unknown Accident Premises Code: ___ Employer (E) ___ Other (X) ACCIDENT/INJURY ___ Lessee (L) ___ Employee Residence R( ) Name the object or substance that directly injured the employee. (ex. knife, floor, acid, oil): Accident Site Organization Name: Accident Site Street, City, State, & Postal Code: Specify activity the employee was engaged in when the event occurred. (ex. cutting metal plate for flooring) Indicate if activity was part of normal duties: Accident Location Narrative (if no street address): Accident Site County/Parish: Witness Name & Business Phone Number: Initial Treatment Code (check one): Initial Medical Provider Name: Managed Care Organization Name or ID Number: ___ no medical treatment (0) ___ minor/on-site treatment (1) ___ clinic/hospital visit (2) Initial Medical Provider Physical Address, City, State, & Postal Code: MEDICAL ___ emergency care (3) ICD Primary Diagnostic Code (if known): ___ hospitalization > 24 hours (4) ___ future medical treatment/lost time anticipated (5) Preparer’s Name & Title: Preparer's Company Name: Phone Number: Date: Form 14-0001 (Last Updated March 2023)
