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First Report of Injury (FROI)
Employer's initial notification of workplace injury or illness — required by all 50 states
⚡ Required Within 24–72 Hours
🔒 HIPAA Protected
✓ EDI Submission Ready
1
Employer Info
2
Injured Worker
3
Injury Details
4
Medical & Witnesses
5
Review & Submit
Fields marked
*
are required for submission. This form must be filed with your state workers' compensation board within the required timeframe.
1
Employer Information
Pre-populated from your account
Legal Business Name
*
Federal EIN
*
Principal Business Address
*
State of Employment
*
Virginia (VA)
Maryland (MD)
Washington DC
California (CA)
NAICS Industry Code
*
Workers' Comp Carrier
*
Policy Number
*
Contact Person
Contact Phone
2
Injured Worker Information
First Name
*
Middle Initial
Last Name
*
Date of Birth
*
Required for claim processing
Social Security Number
Last 4 digits acceptable per state
Employee ID
Home Address
*
City / State / ZIP
*
Date of Hire
*
Job Title / Occupation
*
Department
Employment Status
*
Full-Time
Part-Time
Seasonal
Temporary
Contract
Average Weekly Wage
*
Used for indemnity calculation
Pay Frequency
Weekly
Bi-Weekly
Semi-Monthly
Monthly
3
Injury / Illness Details
Date of Injury / Illness
*
Time of Injury
*
Date Employer Notified
*
Date of Last Worked
Specific Location of Injury
*
Describe How the Injury Occurred
*
Part(s) of Body Injured
*
Head/Skull
Face/Eye(s)
Neck/Cervical
Shoulder(s)
Upper Back
Lower Back
Arm(s)/Elbow(s)
Wrist(s)/Hand(s)
Finger(s)/Thumb
Hip(s)/Pelvis
Knee(s)/Leg(s)
Ankle(s)/Foot/Feet
Chest/Ribs
Internal Organs
Multiple/Other
Nature of Injury
*
Select injury type...
Strain/Sprain
Contusion/Bruise
Laceration/Cut
Fracture/Break
Dislocation
Burn (Thermal)
Chemical Exposure
Cumulative Trauma / Repetitive Motion
Crush Injury
Amputation
Occupational Disease/Illness
Hearing Loss
Psychological/Mental Health
Death
Cause of Injury
*
Select cause...
Overexertion / Lifting
Fall — Same Level (Slip/Trip)
Fall — Different Level
Struck By Object
Caught In/Between
Motor Vehicle Accident
Repetitive Motion
Assault / Violence
Exposure to Substance
Electrical Contact
Other
Severity Classification
*
Medical Only (No Lost Time)
Lost Time — Less Than 7 Days
Lost Time — 7+ Days (OSHA Recordable)
Permanent Partial Disability
Permanent Total Disability
Fatality
Was Employee Hospitalized?
*
Yes — Inpatient
Emergency Room Only
No
OSHA Recordable?
*
Yes
No
Under Review
4
Medical Treatment & Witnesses
Date of First Medical Treatment
Treating Physician / Facility
Medical Facility Address
Physician's Preliminary Diagnosis
Supervisor / Witness 1 Name
Supervisor Phone
Witness 2 Name (if any)
Supervisor's Account of Incident
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