To make filling out this form faster, have the following items on hand:

• Employer name
• Employee's:
• Name
• Address
• Phone number
• Social Security number (or other type of ID)
• Date of birth
• Hire date (date first employed)
• Date of injury
• Date of disability (if available)
• Wage and hours worked
• Description of how the injury occurred
• Information about the injury, including body part and type of injury
• Type of medical treatment sought
• Medical provider

If you have any concerns or additional information, please use the comments box or attach a statement in the document upload box.

• Supporting documents, including work release, wage information, medical reports, witness statements, etc., may also be uploaded
• You may include up to 5 additional files
• Please ensure files are 4 MB or less and are PDF, TIF, JPG, BMP, or PNG attachments

• Review information before submitting
• To correct a submitted FROI, email the claims examiner or submit a revised form
• Revise your FROI online by clicking "Revised" and enter the claim number
• You will need to re-enter the required information
• You may download a PDF after the FROI is submitted. We recommend you save a copy for your records. You may contact your claims examiner if you need a copy