Indiana Worker's Compensation - First Report of Injury (FROI)

Indiana Worker's Compensation - First Report of Injury (FROI)

Commission Row
FOR WORKER'S COMPENSATION BOARD USE ONLY
Jurisdiction
Jurisdiction claim number
Process date

MonthDayYear
Date
PLEASE TYPE or PRINT IN INK Please return completed form electronically by an approved EDI process. NOTE: Your Social Security number is being requested by this state agency in order to pursue its statutory responsibilities Disclosure is voluntary and you will not be penalized for refusal
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
Gender*

MaleFemaleUnknown
Occupation/job title*
Date hired*

MonthDayYear
Date
Employment status
State of hire*
Hourly pay rate (if known)
NCCI class code
Hrs. Day
Days/Wk
Avg Wg /WK
Number of dependents
Name of employer CRG Holdings, LLC.
Insured report number
Address of employer (number and street, city, state, ZIP code)
Location name*
Where incident occured
Incident location address *
Carrier / Administrator claim number
OSHA log number
Report purpose code
Actual location of accident / exposure (if not on employer's premises)
CARRIER / CLAIMS ADMINISTRATOR INFORMATION
Name of claims administrator FCCI Insurance Company

Carrier federal ID number 62-0729866

Address of claims administrator (number and street city, state ZIP code) 6300 University Parkway, Sarasota, FL 34240-8424
WCO100064661-01
Telephone number 800-226-3224/newclaim@lcci-group.com

Name of agent ONI Risk Partners, Inc.

OCCURRENCE/TREATMENT INFORMATION
Date of inj./exp.*

MonthDayYear
Date
Date employer notified*

MonthDayYear
Date
Type of injury/exposure*
Type code
Last work date*

MonthDayYear
Date
Time workday began*

Minutes

AM/PM Option
Date disability began

MonthDayYear
Date
Part of body*
Please indicate if left or right (when applicable)
Part code
Return to work date (if known)

MonthDayYear
Date
Date of death

MonthDayYear
Date
Injury/exposure occurred on employer's premises?

YesNo
Name of restaurant contact*
Phone number of restaurant contact*
Department or location where accident/exposure occurred*
All equipment, materials, or chemicals involved in accident*
Specific activity engaged in during accident/exposure*
Work process employee engaged in during accident/exposure*
How injury/exposure occurred. Describe the sequence of events and include any relevant objects or substances*
Cause of injury code
Name of physician/health care provider (if known/if applicable)
If known
Hospital or offsite treatment (name and address if known/if applicable)
If known
Name of witness (if applicable)
If applicable
Telephone number
Phone number of witness
Telephone number (if applicable)
Name of preparer*
Preparer title*
Preparer email*
example@example.com
Preparer telephone number*
Phone number of person completing the form
Date prepared*

MonthDayYear
Date
Date administrator notified*

MonthDayYear
Date
If your Team Member declines to seek medical treatment

Upload or take a photo of the Declination Form
File Upload

Cancelof
Minor: By Employer Minor: Clinic / Hospital Emergency Care Hospitalized > 24 Hours Future Major Medical / Lost Time Anticipated

An employer's failure to report an occupational injury or illness may result in a $50 fine (IC 22-3-4-13
Should be Empty:

Indiana Worker's Compensation - First Report of Injury (FROI)

CARRIER / CLAIMS ADMINISTRATOR INFORMATION

WCO100064661-01

If your Team Member declines to seek medical treatment