Drsxxx PDF Details

The Drsxxx form, formally known as the First Report of an Injury, Occupational Disease or Death, serves as a critical document in the Ohio Workers' Compensation process. It is designed for injured workers, employers, and healthcare providers to officially report an injury or disease that occurred in the workplace or a death resulting from such. This comprehensive form facilitates a streamlined approach to claiming benefits by capturing all necessary details related to the incident, the injured worker, and their employment. Completing the form accurately and in its entirety is instrumental in reducing the time required to assess and process the claim. It involves detailing the injured party's personal and employment information, specifics of the injury or disease, treatment details, and a section for employers' certification or rejection of the claim. In addition, it includes a consent section for the release of medical and other relevant information necessary for claim administration. By submitting this form to the appropriate managing care organization (MCO) or directly to the Bureau of Workers' Compensation (BWC) if necessary, it triggers the official process towards evaluating and providing the required support and compensation to the injured worker under Ohio law. The form can be submitted online, delivered by mail, or faxed, offering flexibility to promptly meet the needs of all parties involved.

QuestionAnswer
Form NameDrsxxx
Form Length4 pages
Fillable?Yes
Fillable fields114
Avg. time to fill out23 min 52 sec
Other namesbwc 1101, first report of injury ohio, ohio bwc froi, ohio bwc froi form

Form Preview Example

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

1Complete as much of all three sections of this form as possible to reduce the time necessary in determining the claim. If this form is completed by the injured worker at the irst visit to a medical provider, the injured worker may give the FROI to the provider to complete the treatment information section.The provider can then submit the FROI to the MCO.

2Deliver, mail or fax the completed document to your employer or your employer's managed care organization (MCO).

3If you do not know your employer's MCO, contact BWC at 1-800-644-6292 and follow the prompts, or use the MCO on BWC's Web site at www. bwc.ohio.gov.

4If you are unable to determine your MCO, mail or fax this form to the BWC customer service ofice closest to your home. For information on your local customer service ofice, please visit www.bwc.ohio.gov., or call 1-800-644-6292.

Injured workers employed by a self-insuring employer

Complete this form and give to your employer.

Your employer should be able to tell you if he or she is a self-insuring employer.

If your employer is self-insuring and you ile this information with BWC, processing delays may occur.

For assistance in completing this form, call your BWC customer service office Monday through Friday, 8 a.m. – 5 p.m.

Cambridge

Dayton

Mansfield

61501 Southgate Road

3401 Park Center Drive, Suite 100

240 Tappan Drive, N., Suite A

Cambridge, OH 43725-9114

Dayton, OH 45414-2577

Ontario, OH 44906-1366

Phone: 740-435-4200

Phone: 937-264-5000

Phone: 419-747-4090

Fax: 866-281-9351

Fax: 866-281-9356

Fax: 866-336-8350

Canton

Garfield Heights

Portsmouth

339 E. Maple St., Suite 200

4800 E. 131 St., Suite A

1005 Fourth St.

North Canton, OH 44720-2593

Garfield Heights, OH 44105-7132

Portsmouth, OH 45662-4315

Phone: 330-438-0638

Phone: 216-584-0100

Phone: 740-353-2187

Toll free: 800-713-0991

Toll free: 800-224-6446

Fax: 866-336-8353

Fax: 866-281-9352

Fax: 866-457-0590

 

 

 

Toledo

Cleveland

Governor’s Hill

P.O. Box 794

615 Superior Ave. W.

8650 Governor’s Hill Drive

1 Government Center, Suite 1136

Cleveland, OH 44113-1889

Cincinnati, OH 45249-1369

Toledo, OH 43697-0794

Phone: 216-787-3050

Phone: 513-583-4400

Phone: 419-245-2700

Toll free: 800-821-7075

Fax: 866-281-9357

Fax: 866-457-0594

Fax: 866-336-8345

 

 

 

Lima

Youngstown

Columbus

2025 E. Fourth St.

242 Federal Plaza, W., Suite 200

30 W. Spring St.

Lima, OH 45804-4101

Youngstown, OH 44503-1206

Columbus, OH 43215-2256

Phone: 419-227-3127

Phone: 330-797-5500

Phone: 614-728-5416

Toll free: 888-419-3127

Toll free: 800-551-6446

Fax: 866-336-8352

Fax: 866-336-8346

Fax: 866-457-0596

Completion

 

Last name, first name, middle initial

 

 

 

 

 

 

 

Social Security number

 

Marital status

 

Date of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

 

 

 

 

 

 

 

 

 

 

 

 

instructions

info.

Home mailing address

1

 

 

 

 

 

 

 

 

 

Sex

 

 

 

 

Married

 

Number of dependents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

Divorced

 

 

 

 

 

 

 

 

 

 

 

 

(continued)

 

City

 

 

 

 

 

 

State

 

9-digit ZIP code

Country if different from USA

Separated

 

Department name

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

injury/disease/death

Wage rate

 

 

 

 

Hour

Month

Week

What days of the week do you usually work?

 

 

 

Regular work hours

 

 

 

 

 

 

 

 

$________________ Per: 3

Year

Other _________________

4

 

Sun

Mon

Tues

Wed

Thur

 

Fri

Sat

From ____ To ____ 4

 

 

 

 

 

 

 

Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau

5

 

 

 

 

Occupation or job title

6

 

 

 

 

 

 

 

 

 

of Workers' Compensation? YES

NO If yes, please explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 of injury/disease

8

Time of injury

 

 

If fatal, give date of death

 

Time employee began

Date last worked

9

Date returned to work

 

 

 

 

 

 

 

 

 

 

__________

 

a.m.

p.m.

 

 

 

 

 

 

work

a.m.

p.m.

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

Date hired

 

 

 

State where hired

11

 

 

 

Date employer notified 12

State where supervised

13

 

 

 

 

 

 

 

 

 

 

 

 

 

and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of accident (Describe the sequence of events that directly

14

 

 

 

 

 

 

 

Type of injury/disease and part(s) of body affected

 

 

 

 

 

 

 

 

injured the employee, or caused the disease or death)

 

 

 

 

 

 

 

 

 

 

 

(for example: sprain of lower left back, etc.)

 

15

 

 

 

 

 

 

 

 

worker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injured

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

16

 

 

 

 

 

 

Date

 

 

 

E-mail address

 

 

Telephone number

Work number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

( )

 

 

 

( )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Home address: Enter the home address where the

 

9 Date last worked: Enter the last day worked as a result

 

 

 

 

injured worker lives. Include the apartment number,

 

 

 

of this injury, occupational disease or death.

 

 

 

 

if applicable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• If the post ofice does not deliver mail to the

10

 

Date returned to work: Enter the date the injured

 

 

 

 

 

home address, list the mailing address instead

 

 

 

worker returned to work after the injury or

 

 

 

 

 

of the home address.

 

 

 

 

 

 

 

 

 

 

 

 

occupational disease.

 

 

 

 

 

 

 

 

 

 

info.

2

Department name: Enter the injured worker's

11 State where hired: Enter the state where the injured

 

 

 

department or area name where he/she normally

 

 

 

 

 

 

worker was hired by the employer listed on this

 

 

 

reports for work.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

application.

 

 

 

 

 

 

 

 

 

 

 

 

 

injury/disease/death

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 Wage rate: Enter the injured worker's rate of pay, and

12 Date employer notiied: Enter the date the employer

 

 

 

then select how often it is received. (If the pay rate

 

 

 

 

 

 

wasnotiiedoftheinjury,occupationaldiseaseordeath.

 

 

 

being reported is not hourly, report the gross amount.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• If eight or more days of work will be missed, BWC

13 State where supervised: Enter the state where the

 

 

 

 

needs wage information for the 52 weeks prior to

 

 

 

 

 

 

 

injuredworkerwassupervisedbytheemployerlisted

 

 

 

 

the date of injury. Submit wage information using

 

 

 

 

 

 

 

 

 

 

on this application.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

employer payroll reports, wage statement (BWC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

form C-94-A), W-2s, etc.

 

 

 

 

 

 

 

 

 

14 Description of accident: Describe in detail the events

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4 What days of the week do you usually work? What

 

 

 

that caused the injury, occupational disease or death.

 

 

 

are your regular work hours: Enter the days and

 

 

 

Attach additional sheets, if necessary.

 

 

and

 

 

 

 

 

 

 

hours the injured worker normally works.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• If the days worked vary from week to week, list the

15

 

Type of injury/disease and part of body affected:

 

 

worker

 

 

number of hours worked in an average week.

 

 

 

 

 

 

Describethenatureoftheinjury,occupationaldisease

 

 

5

Wages:Ifyoureceivedwagesduringdisability,please

 

 

 

or death.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indicate the part(s) of body injured, affected or that

 

 

 

explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

caused the death.

 

 

 

 

 

 

 

 

 

 

 

 

Injured

6 Occupationorjobtitle:Entertheinjuredworker'stype

 

 

 

Examples:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• Laceration of irst toe, left foot;

 

 

 

 

 

 

 

 

 

 

 

of occupation or actual job title at the time of injury,

 

 

 

• Sprain of lower right back; etc.

 

 

 

 

 

 

 

 

 

 

 

occupational disease or death.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16 Injured worker signature (injured workers only):

 

 

 

7

Employer name: Enter the name of the injured

 

 

 

 

 

 

Please

read

the

Benefit application/medical

 

 

 

 

worker's

employer at the time of

the

injury,

 

 

 

 

 

 

 

 

 

 

release information before signing and dating

 

 

 

 

occupational disease or death.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

this form.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8 Date of injury/disease: Enter the date injured worker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

was injured. OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the injured worker contracted an occupational

 

 

 

 

 

 

 

 

 

 

 

 

Instructions

 

 

 

 

 

disease, determine which of the following happened

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

continued

 

 

 

 

 

most recently:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

on last page

 

 

 

 

 

• The occupational disease was diagnosed by a medical provider;

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[

 

 

 

 

• The irst medical treatment;

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• The injured worker irst quit work, due to the occupational disease.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter this as the date of occupational disease.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Report of an Injury, Occupational Disease or Death

By signing this form, I:

Elect to only receive compensation and/or beneits that are provided for in this claim under Ohio workers' compensation laws;

Waive and release my right to receive compensation and beneits under the workers' compensation laws of another state for the injury or occupational disease, or death resulting from an injury or occupational disease, for which I am iling this claim;

Agree that I have not and will not ile a claim in another state for the injury or occupational disease or death resulting from an injury or occupational disease for which I am iling this claim;

Conirm that I have not received compensation and/or beneits under the workers’ compensation laws of another state for this claim, and that I will notify BWC immediately upon receiving any compensation or beneits from any source for this claim.

WARNING:

Any person who obtains compensation from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statementsoracceptingcompensationtowhichhe or she is not entitled, is subject to felony criminal prosecution for fraud.

(R.C. 2913.48)

Injured worker and injury/disease/death info.

Last name, first name, middle initial

 

 

 

 

 

 

 

 

Social Security number

 

Marital status

Date of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

 

 

 

 

 

 

 

 

Home mailing address

 

 

 

 

 

 

 

 

 

Sex

 

 

 

Married

Number of dependents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

Divorced

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Separated

 

 

 

 

 

 

 

City

 

 

 

State

 

9-digit ZIP code

Country if different from USA

 

Department name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wage rate

 

 

Hour

Month

Week

What days of the week do you usually work?

 

 

Regular work hours

$

 

 

Per:

Year

Other

 

 

Sun

Mon

Tues

Wed Thur

Fri

Sat

From

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau

Occupation or job title

 

 

 

 

of Workers' Compensation?

Yes

No

If yes, please explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer name

Mailing address (number and street, city or town, state, ZIP code and county)

Location, if different from mailing address

Was the place of accident or exposure on employer's premises?

Yes

No

 

 

 

 

 

 

 

 

(If no, give accident location, street address, city, state and ZIP code)

 

 

 

 

 

 

 

 

 

Date of injury/disease

Time of injury

 

If fatal, give date of death

Time employee

 

 

Date last worked

Date returned to work

 

 

 

a.m.

p.m.

 

 

 

began work

a.m. p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date hired

 

 

 

State where hired

 

 

Date employer notified

 

 

 

State where supervised

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of accident (Describe the sequence of events that directly

 

 

 

 

 

Type of injury/disease and part(s) of body affected

injured the employee, or caused the disease or death.)

 

 

 

 

 

 

(For example: sprain of lower left back)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

(

)

Treatment info.

Health-care provider name

Telephone number

Fax number

Initial treatment date

 

(

)

(

)

 

 

Street address

City

 

 

 

State

9-digit ZIP code

 

 

 

 

 

 

 

Diagnosis(es): Include ICD code(s)

Will the incident cause the injured worker to

 

 

 

 

 

 

 

miss eight or more days of work?

Yes

No

Is the injury causally related to the industrial incident?

Yes

No

 

 

 

 

 

 

 

 

E code

 

 

 

11-digit BWC provider number

Date

 

 

 

 

 

 

 

 

 

 

 

Health-care provider signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer policy number

 

 

 

 

 

Check

Employer is self-insuring

 

 

 

 

 

 

 

 

 

 

 

 

if

Injured worker is owner/partner/member of firm

 

 

Telephone number

 

Fax number

 

E-mail address

 

Federal ID number

Manual number

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

 

 

info.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was employee treated in an emergency room?

Yes No

 

Was employee hospitalized overnight as an inpatient?

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer

If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certification - The employer

 

 

 

Rejection - The employer

For self-insuring employers only

 

 

 

 

 

 

Clarification - The employer clarifies

 

 

 

certifies that the facts in this

 

 

 

rejects the validity of this claim for

 

 

 

application are correct and valid.

 

 

the reason(s) listed below:

and allows the claim for the condition(s) below:

 

 

 

 

 

 

 

 

 

 

 

 

Medical only

 

Lost time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer signature and title

 

 

 

 

 

 

 

 

Date

 

OSHA case number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BWC-1101 (Rev. 6/12/2014)

 

 

 

 

 

 

 

 

This form meets OSHA 301 requirements

FROI-1 (Combines C-1, C-2, C-3, C-6, C-50, OD-1, OD-1-22)

 

 

 

 

 

 

Completion instructions

(continued)

Treatment info.

 

Health-care provider name

 

 

Telephone number

Fax number

 

 

 

 

Initial treatment date

 

 

 

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

info.

Street address

 

 

City

 

 

 

 

 

State

9-digit ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis(es): Include ICD code(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment

 

 

1

SAMPLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E code 3

 

 

 

2

 

11-digit BWC provider number

4

 

Date

 

 

 

Will the incident cause the injured worker to miss eight or more

 

 

 

 

 

 

 

 

 

 

 

 

 

 

days of work?

 

Yes

No

Is the injury causally related to the industrial incident?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health-care provider signature

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1Indicate the diagnosis and ICD codes for conditions being treated as a result of the injury.

2Indicate the treating provider's medical opinion that the injury sustained is causally related to the industrial incident, that the injury could result from the method (manner) of the accident, as described by the injured worker. It must be clear that the diagnosis in all probability occurred as a result of the injury.

3Providing a valid E code will enable us to determine the claim more quickly and eficiently.

4Enter the physician's or health-care provider's 11-digit BWC-assigned provider number.

5Signature of the health-care provider completing this form.

 

 

 

1 Employer policy number

 

 

 

 

 

Check

Employer is self-insuring

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

if

Injured worker is owner/partner/member of firm

 

 

info.

Telephone number

 

Fax number

 

 

 

E-mail address

 

 

Federal ID number

Manual number

2

 

(

)

 

( )

 

 

 

 

 

 

 

 

 

 

 

 

Was employee treated in an emergency room?

 

Yes

No

Was employee hospitalized as an inpatient?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certification - The employer

 

 

Rejection - The employer

 

 

 

For self-insuring employers only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer

 

 

certiies that the facts in this

SAMPLE

Clarification - The employer clariies

 

 

3

 

4

rejects the validity of this claim for

 

 

 

 

 

application are correct and valid.

the reason(s) listed below:

 

 

 

5 and allows the claim for the condition(s) below:

 

 

Employer: signature and title

 

 

 

 

 

 

 

 

Date

 

OSHA case number 6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer info.

1Enter the employer's BWC-assigned policy number, which is located on the BWC certiicate of coverage.

2Enter the four-digit code that indicates the injured worker's job classiication, located on the semiannual payroll report.

If you do not know the injured worker's manual number, call 1-800-644-6292 and follow the prompts.

3If certiication is selected and the claim is allowed, it will promptly be paid. Employers certifying a claim waive both the notice of receipt and notice of irst order of compensation.

4If rejection is selected, use the space provided to list the reasons for rejection. Attach additional sheets, if necessary.

5Self-insuring employers that choose to clarify certiication may use the space provided. Attach additional sheet, if necessary.

6If this is an OSHA-reportable injury, include the case number assigned by the employer.This form meets OSHA 301 requirements and may be used in lieu of the OSHA 301 when reporting recordable injuries and illnesses to the federal government.

Note:

If your employee misses eight or more days of work, BWC will need wage information for the 52 weeks prior to the date of injury. Submit wage information using employer payroll reports, wage statement (BWC form C-94-A), W-2s, etc.

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