online form First Report of an Injury, en-USOccupational Disease or Death (FROI)en-USInstructionsen-USTo expedite your claim, you can complete and submit this form online aten-US en-USwww.bwc.ohio.gov. 225 þ en-USIf submitting the hard copy form, complete as much of this form as possible to reduce the time necessary en-USfor BWC to determine the claim. 225 þ en-USIf you complete this form at your 037rst visit to a medical provider, the provider should complete the treatment en-USinformation section. The provider can then submit the FROI to the managed care organization (MCO). 225 þ en-USYou should also report this injury to your employer.en-USWhere do I 037le the hard copy FROI? en-USFor injured workers whose employer is self-insureden-US: Send the form to your self-insuring employer. If you are not en-USsure if your employer is self-insured, ask your employer. en-USFor all other injured workers: en-USFax the form to 1-866-336-8352, or send it to your local BWC customer service of037ce. þ en-USHome address: Address where you live, including the en-USapartment number, if applicable. 225 þ If the post of037ce does not deliver mail to the home en-USaddress, list the mailing address. þ Department name: Enter the department where you en-USnormally report for work. þ Wage rate: Enter your rate of pay, then select how often en-USyou receive it. (If the pay rate reported is not hourly, report en-USthe gross amount.) 225 þ If you will miss eight or more days of work, BWC en-USneeds wage information for the 52 weeks prior to the en-USdate of injury. þ What days of the week do you usually work? What are your en-USregular work hours: Enter the days and hours you normally en-USwork. 225 þ If the days worked vary from week to week, list the en-USnumber of hours worked in an average week. þ en-USWages: If you received wages during disability, please explain. þ Occupation or job title: Enter the type of occupation or job en-UStitle at the time of injury, occupational disease or death. þ Employer name: Enter the name of your employer at the en-UStime of the injury, occupational disease or death. þ Date of injury/disease: Enter the date you were injured, or en-USif you contracted an occupational disease, determine which en-USof the following happened most recently: 225 þ The occupational disease was diagnosed by a en-USmedical provider; 225 þ The 037rst medical treatment; 225 þ The injured worker 037rst quit work, due to the en-USoccupational disease.en-USEnter this as the date of occupational disease.en-USFor death claims, enter the injured worker date of death. þ Date last worked: Enter the last day worked as a result of en-USthis injury, occupational disease. þ Date returned to work: Enter the date you returned to work en-USafter the injury or occupational disease. þ State where hired: Enter the state where the employer en-USlisted on this application hired you. þ Date employer noti037ed: Enter the date that you noti037ed en-USthe employer of the injury, occupational disease or death. þ State where supervised: Enter the state where the employer en-USlisted on the application supervised you. þ Description of accident: Describe in detail the events that en-UScaused the injury, occupational disease or death. þ Type of injury/disease and part of body affected: Describe en-USthe nature of the injury, occupational disease or death. en-USIndicate the part(s) of body injured, affected or that caused en-USthe death.en-USExamples: 225 þ en-USLaceration of 037rst toe, left foot; 225 þ en-USSprain of lower right back; etc. þ Injured worker signature (injured workers only): Please en-USread the Bene037t application/Medical release information en-USbefore signing and dating this form. Injured worker and injury/disease/death info. 1 9 10 11 12 13 14 15 16 2 3 4 5 6 7 8 American LegalNet, Inc. www.FormsWorkFlow.com en-USEmployer info. 1 Enter the employer's BWC-assigned policy number, en-USwhich is located on the BWC certi037cate of coverage.en-USEnter the four-digit code that indicates the injured en-USworker's job classi037cation. 225 þ If you do not know the injured worker's manual en-USnumber, call en-US1-800-644-6292,en-US and follow the en-USprompts.en-USIf you select certi037cation, and BWC allows the claim, en-USBWC will promptly pay it. Employers certifying a en-USclaim waive both the notice of receipt and notice en-USof 037rst order of compensation.en-USIf you select rejection, use the space provided to en-USlist the reasons for rejection. Attach additional en-USsheets, if necessary. 2 3 4 Self-insuring employers that choose to clarify en-UScerti037cation may use the space provided. Attach en-USadditional sheets, if necessary.en-USIf this is an Occupational Safety and Health en-USAdministration (OSHA)-reportable injury, include en-USthe case number assigned by the employer. This en-USform meets OSHA 301 requirements. You may use it en-USin lieu of the OSHA 301 when reporting recordable en-USinjuries and illnesses to the federal government.en-USNote:en-USIf your employee misses eight or more days of work, en-USBWC will need wage information for the 52 weeks en-USprior to the date of injury. Submit wage information en-USusing employer payroll reports, wage statement en-US(BWC's Employer Report of Employee Earnings), en-USW-2s, etc. 5 6 Treatment info. en-USCompletion instructionsen-US(continued) 1 Indicate the diagnosis and ICD codes for conditions treated as a result of the injury. en-USIndicate the treating provider's medical opinion that the injury sustained is causally related to the industrial en-USincident, that the injury could result from the method (manner) of the accident, as described by the injured en-USworker. It must be clear that the diagnosis in all probability occurred as a result of the injury.en-USProviding a valid E code will enable us to determine the claim more quickly and ef037ciently.en-USEnter the physician's or health-care provider's 11-digit BWC-assigned provider number.en-USSignature of the health-care provider completing this form. 2 3 4 SAMPLE en-USEmployer policy numberen-USEmployer is self-insuringen-USInjured worker is owner/partner/member of 037rmen-USFederal ID number en-USManual number en-USEmployer info. en-USCheck en-USif en-USWas employee treated in an emergency room? Yes No en-USWas employee hospitalized as an inpatient? Yes No en-USIf treatment was given away from work site, provide the facility name, street address, city, state and ZIP code en-USFor self-insuring employers onlyen-USClari037cation -en-US The employer en-USclari037esen-USand allows the claim for the condition(s) below:en-USRejection -en-US The employer en-USrejectsen-US the validity of this claim for en-USthe reason(s) listed below:en-USCerti037cation -en-US en-USThe employer en-UScerti037esen-US that the facts in this en-USapplication are correct and valid. en-USOSHA case numberen-USDateen-US Employer: signature and title 1 en-US 3 en-US 4 en-US 5 6 en-US en-USTelephone numberen-US( )en-USFax numberen-US( )en-USE-mail address 2 en-US en-USSAMPLE en-USHealth-care provider nameen-USStreet addressen-USDiagnosis(es): Include ICD code(s) en-USE code en-USTelephone numberen-USFax numberen-US( )en-USInitial treatment dateen-USCityen-USStateen-US9-digit ZIP codeen-USWill the incident cause the injured worker to miss eight or more en-USdays of work?en-USYes No en-USIs the injury causally related to the industrial incident?en-USYes No en-US11-digit BWC provider numberen-USDate en-USHealth-care provider signature 1 en-US 5 en-US 2 en-US 4 en-US 3 en-US 5 Treatment info. en-US( ) American LegalNet, Inc. www.FormsWorkFlow.com en-USWARNING:en-USAny person who obtains compensation from en-USBWC or self-insuring employers by knowingly en-USmisrepresenting or concealing facts, making false en-USstatements or accepting compensation to which he en-USor she is not entitled, is subject to felony criminal en-USprosecution for fraud. þ n n (R.C. 2913.48) en-USFirst Report of an Injury,en-USOccupational Disease or Death en-USLast name, 037rst name, middle initialen-USSocial Security numberen-USMarital statusen-US Singleen-US Marrieden-US Divorceden-US Separateden-US Widowed e