Ohio Worker's Compensation - First Report of Injury (FROI), Occupational Disease, or Death

Ohio Worker's Compensation - First Report of Injury (FROI), Occupational Disease, or Death
Submit the form to BWC in one of the following ways. Online: www.bwc.ohio.gov, Fax: 1-866-336-8352, Mail: BWC Mail Processing Center, Attn: Claims, 30 W. Spring St. Columbus, OH 43215 Note: If you work for a self-insuring employer, submit this form to your employer’s workers’ comp manager.
Name (last, first, middle)*
Date of birth*

MonthDayYear
Date
Social Security Number
Please ask the team member for this information
Phone number*
Team member phone number
Team member email *
Sex*

MaleFemale
Address*

Team member mailing address; add apartment number or P.O. Box, if applicable

Street Address Line 2

CityState

ZIP code
Date of injury/disease*

MonthDayYear
Restaurant name
Restaurant phone number*
Please enter a valid phone number
Restaurant address

Employer address

Street Address Line 2

CityState

ZIP code
Was the injured worker hired through a temp agency? If yes, name of temp agency

YesNo
Date hired*

MonthDayYear
Date
Job title*
State where hired*
State where supervised*
Wage rate; $ per hour (if known)
Number of hours scheduled to work the week of this injury
Work number for call-offs (Number injured worker calls to reach supervisor)
Part(s) of body affected (for example: left knee, right index finger)*
Accident description. Describe the sequence of events that directly caused the injury or death*
Yes

Will the incident cause the injured worker to miss 8 or more days from work?No
Injured worker start time *

Minutes

AM/PM Option
Time of injury*

Minutes

AM/PM Option
Date employer notified*

MonthDayYear
Date
Was any part of a workday missed due to
Date last worked

MonthDayYear
Date
No

the injury?Yes
If the injured worker has returned to work, provide the date.
Was the place of the accident or exposure on employer's premises?*

YesNo (If no, give accident location: street address, city, state, and ZIP code below)
If no - accident location: street address, city, state, and ZIP code
No If no, give accident location, street address, city, state, and ZIP code.

Was injured worker hospitalized overnight? YesNoFax number
Initial treatment date

MonthDayYear
Date
Health-care office/facility name
Treating physician/provider name (if known/if applicable)
Health-care office/facility name address (if known/if applicable)

Street address

Street Address Line 2

CityState

ZIP code
If the injury resulted in death, answer the following.
Date of death Decedent’s marital status

SingleMarriedDivorcedSeparatedWidowed Decedent’s number of dependents
To be completed by the injured worker.

By signing this form, I:
- Elect to only receive compensation, benefits, or both provided for in this claim under Ohio’s workers’ compensation laws.
- Understand, waive, and release my right to receive compensation and benefits under the workers’ compensation laws of another state for the injury, occupational disease, or death resulting from an injury or occupational disease for which I am filing this claim.
- Confirm I have not received compensation and benefits under the workers’ compensation laws of another state for this claim, and I will notify BWC immediately upon receiving any compensation or benefits from any source for this claim.
- Will not file and have not filed a claim in another state for the injury, occupational disease, or death resulting from an injury or occupational disease for which I am filing this claim.
Furthermore, I understand that:
- Upon request, my treating providers may submit to BWC, my employer, my employer’s managed care organization or qualified health plan, or their authorized representatives medical, psychological, psychiatric, or vocational documentation relating causally or historically to physical or mental injuries relevant to this claim and necessary for me to obtain medical services, benefits, or compensation.
- Proper administration of this claim may require BWC to review and share with the employers of record, their authorized representatives, or my authorized representative any information or record maintained in this claim, or in my previous or future claims.
- Information or records maintained in my previous or future claims may affect decisions made in this claim.
- Any person who obtains compensation or benefits from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements, or accepting compensation or benefits to which he or she is not entitled, is subject to felony criminal prosecution for fraud (Ohio Revised Code 2913.48 I certify that I have read, understand, and agree to the above statements and the information contained on this form is true and accurate to the best of my knowledge. Injured worker signatureDate
Team member signature*

Clear
Date signed*
To be completed by the treating provider
Diagnosises-narrative description including as appropriate, the location and body part, and ICD codes right knee” not “pain right knee”, “toxic effect of ammonia” not “exposure to ammonia”, “contusion to the head” not “headache”.
Initial treatment date

MonthDayYear
Date
Are the medical conditions you have listed above causally related to the reported work-related accident or occupational disease?

YesNo
No

Are you the physician of record?Yes
Treating physician/Provider’s name (Print)
Treating physician/Provider’s signature
BWC provider number
Date

MonthDayYear
Date
To be completed by the employer
Employer name
Employer county
Fax number
Email address
example@example.com
Employer policy number
Federal ID number
Federal ID number

Owner/Sole proprietorPartnerInjured worker is Check box, if applicable
Individual incorporated as a corporation
For all employers:*

Certification - I certify the facts in this application are correct and valid.Rejection – I reject the validity of this claim for the reason(s) listed below.
For self-insuring employers only:
Medical only

For self-insuring employers only:Lost time
Preparer's Name and title*
Preparer's signature*

Clear
Preparer's email address*
example@example.com
Date prepared*

MonthDayYear
Date
If your Team Member declines to seek medical treatment

Upload or take a photo of the Declination Form
File Upload

Cancelof
Should be Empty:

Ohio Worker's Compensation - First Report of Injury (FROI), Occupational Disease, or Death

If your Team Member declines to seek medical treatment