First Report of an Injury, Occupational Disease or Death This form can be completed and submitted online at www.bwc.ohio.gov Report your injury by completing all three sections of this form 1 Completeasmuchofallthreesectionsofthis formaspossibletoreducethetimenecessaryin determiningtheclaim.Ifthisformiscompleted bytheinjuredworkeratthefirstvisittoamedical provider,theinjuredworkermaygivetheFROI to the provider to complete the treatment informationsection. heprovidercanthensubmit T theFROItotheMCO. youremployeroryouremployer'smanagedcare organization(MCO). 3 Ifyoudonotknowyouremployer'sMCO,contact BWCat1-800-644-6292andfollowtheprompts, or use the MCO on BWC's Web site at www. bwc.ohio.gov. IfyouareunabletodetermineyourMCO,mail orfaxthisformtotheBWCcustomerservice officeclosesttoyourhome.Forinformationon yourlocalcustomerserviceoffice,pleasevisit www.bwc.ohio.gov.,orcall 1-800-644-6292. 4 2 Deliver,mailorfaxthecompleteddocumentto Injured workers employed by a self-insuring employer ·Completethisformandgivetoyouremployer. ·Youremployershouldbeabletotellyouifheorsheisaself-insuringemployer. ·Ifyouremployerisself-insuringandyoufilethisinformationwithBWC,processingdelaysmayoccur. For assistance in completing this form, call your BWC customer service office Monday through Friday, 8 a.m. ­ 5 p.m. Cambridge 61501 Southgate Road Cambridge, OH 43725-9114 Phone: 740-435-4200 Fax: 866-281-9351 Canton 339 E. Maple St., Suite 200 North Canton, OH 44720-2593 Phone: 330-438-0638 Toll free: 800-713-0991 Fax: 866-281-9352 Cleveland 615 Superior Ave. W. Cleveland, OH 44113-1889 Phone: 216-787-3050 Toll free: 800-821-7075 Fax: 866-336-8345 Columbus 30 W. Spring St. Columbus, OH 43215-2256 Phone: 614-728-5416 Fax: 866-336-8352 Dayton 3401 Park Center Drive, Suite 100 Dayton, OH 45414-2577 Phone: 937-264-5000 Fax: 866-281-9356 Garfield Heights 4800 E. 131 St., Suite A Garfield Heights, OH 44105-7132 Phone: 216-584-0100 Toll free: 800-224-6446 Fax: 866-457-0590 Cincinnati­Governor's Hill 8650 Governor's Hill Drive Cincinnati, OH 45249-1369 Phone: 513-583-4400 Fax: 866-281-9357 Lima 2025 E. Fourth St. Lima, OH 45804-4101 Phone: 419-227-3127 Toll free: 888-419-3127 Fax: 866-336-8346 Mansfield 240 Tappan Drive, N., Suite A Ontario, OH 44906-1366 Phone: 419-747-4090 Fax: 866-336-8350 Portsmouth 1005 Fourth St. Portsmouth, OH 45662-4315 Phone: 740-353-2187 Fax: 866-336-8353 Toledo P Box 794 .O. 1 Government Center, Suite 1136 Toledo, OH 43697-0794 Phone: 419-245-2700 Fax: 866-457-0594 Youngstown 242 Federal Plaza, W., Suite 200 Youngstown, OH 44503-1206 Phone: 330-797-5500 Toll free: 800-551-6446 Fax: 866-457-0596 American LegalNet, Inc. www.FormsWorkFlow.com Injured worker and injury/disease/death info. Completion instructions (continued) Last name, first name, middle initial Home mailing address City Wage rate $________________ Per: Social Security number Sex State 9-digit ZIP code 1 3 Hour Year Month Week Other _________________ Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau of Workers' Compensation? YES NO If yes, please explain. 4 Marital status Single Married Male Female Divorced Separated Country if different from USA Widowed What days of the week do you usually work? Sun Mon Tues Wed Thur Date of birth Number of dependents Department name Fri Sat 2 6 4 5 Regular work hours From ____ To ____ Occupation or job title Employer name 7 Mailing address (number and street, city or town, state, ZIP code and county) Location, if different from mailing address Was place of accident or exposure on employer's premises? Yes No If no, give accident location, street address, city, state and ZIP code. Date returned to work Date of injury/disease If fatal, give date of death Time employee began Date last worked Time of injury work ______ a.m. p.m. __________ a.m. p.m. Date hired State where hired State where supervised Date employer notified 8 Description of accident (Describe the sequence of events that directly injured the employee, or caused the disease or death) PLE SAM 11 12 14 9 10 15 13 Type of injury/disease and part(s) of body affected (for example: sprain of lower left back, etc.) Benefit application release of information ­ I am applying for a claim under the Ohio Bureau of Workers' Compensation Act for work-related injuries that I did not inflict. I affirm that I elect to receive compensation and benefits under Ohio's workers' compensation laws for my claim, and I waive and release my right to file for and receive compensation and benefits under the laws of any other state for this claim. I request payment for compensation and/or medical benefits as allowable, and authorize direct payment to my medical providers. I permit and authorize any provider who attends, treats or examines me, the Ohio State Board of Pharmacy, the Ohio Department of Job and Family Services and the Ohio Rehabilitation Services Commission to release medical, psychological, psychiatric, pharmaceutical, vocational and social information. I understand this may include personally identifying information that is casually or historically related to my physical or mental injuries relevant to issues necessary for the administration of my claim to BWC, the Industrial Commission of Ohio, the employer in this claim, the employer's managed care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim. Proper administration of the present claim may require BWC to share claims information with the employers of record (or their authorized representatives) and/or my authorized representative for any and all such previous or future claims. The released claims information may include any record maintained in my claim files. Injured worker signature Date E-mail address Telephone number Work number () () 16 1 Homeaddress:Enterthehomeaddresswherethe injuredworkerlives.Includetheapartmentnumber, ifapplicable. ·If the post office does not deliver mail to the homeaddress,listthemailingaddressinstead ofthehomeaddress. 9 Datelastworked:Enterthelastdayworkedasaresult ofthisinjury,occupationaldiseaseordeath. 10 Date returned to work: Enter the date the injured worker returned to work after the injury or occupationaldisease. 11 Statewherehired:Enterthestatewheretheinjured worker was hired by the employer listed on this application. 12 Dateemployernotified:Enterthedatetheemployer wasnotifiedoftheinjury,occupationaldiseaseor