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First report of injury
Whoops! Something went wrong! If the issue continues to occur, please contact us at
1-800-644-62921-800-644-6292.
If applicable, enter Apt, Suite or Floor number and any other pertinent address information here
Do you want to continue?
Potential duplicate claim(s) found with the information provided. Do you want to continue to file the claim?
Worker
Injured worker
Name
SSN
Birth date
Gender
If applicable, enter Apt, Suite or Floor number and any other pertinent address information here
Mailing address
Either cell or home phone is required.
If applicable, enter Apt, Suite or Floor number and any other pertinent address information here
Employment
Employment
Regular work hours (optional)
Time entered must be in 12-hour hh:mm am/pm format
$
Number you call to reach your supervisor.
Policy
Using the information you've entered, we've found an existing claim(s). Here are the claim numbers.
If you have questions, call 1-800-644-6292.
If you have questions, call 1-800-644-6292.
The policy below is for a self-insuring employer, which means the employer will make the decisions regarding this claim. If this is a medical-only claim, consider filing it directly with the employer to speed up the process. If this is a lost-time claim, you can file it directly with the employer or continue filing it here.
Note: Self-insuring employers are not required to report medical-only claims to BWC. BWC sends all new claims for self-insuring employers directly to them for processing.
Policies are found based on policy and injury information. Please contact us if you cannot find the policy you are looking for.
Policy look-up
You must select a policy to continue.
You must select a policy to continue.
More than 500 records were found. Please narrow your search criteria and try again.
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Results
Employer
Policy number
Employer name
Policy type
DBA
Business name
Physical address
Mailing address
Phone number
Fax number
Email
Name
Email
Phone number
Fax number
No contacts found.
Name
Address
Phone number
Third Party Administrators
No Third Party Administrator found.
MCO
Number
Name
Address
Phone number
Fax number
No MCO found.
InjuryReport
Accident
Describe the sequence of events that directly caused the injury or death.
For example: Sprain left wrist
Time entered must be in 12-hour hh:mm am/pm format
Time entered must be in 12-hour hh:mm am/pm format
Fatality
InjuryReport
Treatment
If applicable, enter Apt, Suite or Floor number and any other pertinent address information here
Diagnosis
Add ICD code
Some ICD codes may require a site and/or location.
You have entered an ICD code that is incomplete, invalid or not specific enough for a BWC claim allowance
ICD 10
Narrative description
Diagnosis
Diagnosis(es)- Please enter a narrative description including as appropriate, the location and body part, and ICD code(s).
Important: If there is an injury, list the condition or disease, not the symptoms or exposure. For example, “sprain right knee” not “pain right knee”, “toxic effect of ammonia” not “exposure to ammonia”, “contusion to the head” not “headache”.
Important: If there is an injury, list the condition or disease, not the symptoms or exposure. For example, “sprain right knee” not “pain right knee”, “toxic effect of ammonia” not “exposure to ammonia”, “contusion to the head” not “headache”.
At least one ICD code is required.
Location
Site
Certification
Your info
Your information
Name
SSN
Birth date
Sex
Mailing address
Email
N/A
Home phone
N/A
Cell phone
N/A
Date of injury
Employer name
N/A
Employer address
N/A
Was the injured worker hired through a temp agency?
N/A
Temp agency name
Policy number
Employer name
Policy type
DBA
Business name
Physical address
Mailing address
Phone number
Fax number
Email
Number
Name
Address
Phone number
Fax number
No MCO found.
Name
Email
Phone number
Fax number
No contacts found.
Name
Address
Phone number
Third Party Administrators
No Third Party Administrator found.
Is the injured worker any of the following?
Owner/Sole proprietor
Is the injured worker any of the following?
Partner
Is the injured worker any of the following?
Individual incorporated as a corporation
Regular work days
N/A
Regular work hours start time
N/A
Regular work hours end time
N/A
Date hired
N/A
Job title
State where hired
N/A
State where supervised
N/A
Number of hours scheduled to work the week of this injury
N/A
Wage per hour
N/A
Work number for call-offs
N/A
Extension
N/A
Accident description
Will the incident cause the injured worker to miss 8 or more days?
N/A
Type of injury/disease and part(s) of body affected
Time injured worker began work
N/A
Time of injury
N/A
Date employer notified
N/A
Date last worked
N/A
If the injured worker has returned to work, provide the date.
N/A
Was any part of a workday missed due to the injury?
Was the place of the accident or exposure on the employer’s premises?
N/A
Accident location
Did this injury result in the injured worker's death?
Date of death
Marital status
N/A
Number of dependents
N/A
Narrative description
N/A
Was the injured worker hospitalized overnight?
N/A
Initial treatment date
N/A
Health-care office/Facility name
N/A
Treating physician/Provider name
N/A
Health-care office/Facility telephone number
N/A
Health-care office/Facility fax number
N/A
Healthcare office/Facility address
N/A
ICD code
Narrative description
Location
Site
Primary
Are you the physician of record?
Are the medical conditions you have listed above causally related to the reported work-related accident or occupational disease?
Role
Name
N/A
Name
N/A
Company name
Blank
Name of person certifying or rejecting
Title of person certifying or rejecting
Type
Clarification – I clarify and allow the claim for the condition(s).
Reason for clarification
Type
Rejection – I reject the validity of this claim
Reason for rejection
Type
Certification – I certify the facts in this application are correct and valid.
Claim allowed as
N/A
Claim allowed as
Medical only
Claim allowed as
Lost time
By signing this form, I:
- Elect to only receive compensation, benefits, or both provided for in this claim under Ohio’s workers’ compensation laws.
- Understand, waive, and release my right to receive compensation and benefits under the workers’ compensation laws of another state for the injury, occupational disease, or death resulting from an injury or occupational disease for which I am filing this claim.
- Confirm I have not received compensation and benefits under the workers’ compensation laws of another state for this claim, and I will notify BWC immediately upon receiving any compensation or benefits from any source for this claim.
- Will not file and have not filed a claim in another state for the injury, occupational disease, or death resulting from an injury or occupational disease for which I am filing this claim.
Furthermore, I understand that:
- Upon request, my treating providers may submit to BWC, my employer, my employer’s managed care organization or qualified health plan, or their authorized representatives medical, psychological, psychiatric, or vocational documentation relating causally or historically to physical or mental injuries relevant to this claim and necessary for me to obtain medical services, benefits, or compensation.
- Proper administration of this claim may require BWC to review and share with the employers of record, their authorized representatives, or my authorized representative any information or record maintained in this claim, or in my previous or future claims.
- Information or records maintained in my previous or future claims may affect decisions made in this claim.
- Any person who obtains compensation or benefits from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements, or accepting compensation or benefits to which he or she is not entitled, is subject to felony criminal prosecution for fraud (Ohio Revised Code 2913.48).
Ohio Bureau of Workers' Compensation
Electronic Signature
Electronic Signature
Providing information to BWC is your choice. By continuing, an electronic signature is created. An electronic signature is equivalent to your handwritten signature. It also acknowledges that you have read and understand the following warning statements. You consent to be legally bound by the terms and conditions of the agreement. Through the use of an electronic signature, you agree that the information you provide is accurate and complete to the best of your knowledge. You also acknowledge that you have read and understand the following warning statements. Please read these notices before proceeding:
-
About Information You Give Us
When you submit sensitive information over the website, that information is encrypted and protected by a secured socket layer (SSL). You can identify secured areas by the checkbox or icon that is displayed on the page. -
About Information You Receive
It is your responsibility to use the information provided to you on this website for its intended purposes and to protect any password(s) issued to you. -
Release of Information
Injured worker benefit application and medical release
An injured worker who submits a First Report of an Injury, Occupational Disease or Death (FROI) is applying for recognition of a claim for work-related injuries that were not purposeful0ly inflicted. Your electronic signature authorizes any provider who attends to, treats or examines you for the related workers' compensation claim to release all medical, psychological, and/or psychiatric information related causally or historically to physical or mental injuries relevant to issues necessary to administer your workers' compensation claim to BWC, the Industrial Commission of Ohio, the employer listed in the claim, that employer's managed care organization, any authorized representatives, and the Ohio Rehabilitation Services Commission.
In addition, when you make any request to BWC, you grant us permission to access your confidential personal information to respond.
-
Fraud Warning
Any person or entity, who with purpose to defraud or knowing that a person is facilitating a fraud, obtains or attempts to obtain compensation or payment from BWC, an employer, or an MCO, by knowingly (1) misrepresenting or concealing a fact, (2) making a false statement, or (3) accepting compensation or payment to which he/she is not entitled, may be subject to repayment to BWC of all funds that have been overpaid, civil remedies, and/or felony criminal prosecution for fraud or other offenses. You are not entitled to Non-Statutory Permanent Total, Temporary Total, Non-Working Wage Loss or Living Maintenance Disability benefits if you are working. -
Identity Fraud
Identity fraud perpetrated through the unauthorized use of BWC systems shall be prosecuted to the full extent of the law.
Ohio Bureau of Workers' Compensation
Electronic Signature
Electronic Signature
You have entered a part of our Web site that asks you to provide an electronic signature before we can process your request.
Please provide your electronic signature before we process your request. When you check I agree, you agree the information you provide is accurate and complete to the best of your knowledge. Any attempts to commit fraud against BWC may be subject to administrative penalties and/or criminal prosecution.
Release of information
Injured worker benefit application and medical release
An injured worker who submits a First Report of an Injury, Occupational Disease or Death (FROI) is applying for recognition of a claim for work-related injuries that were not purposefully inflicted. Your electronic signature authorizes any provider who attends to, treats or examines you for the related workers' compensation claim to release all medical, psychological, and/or psychiatric information related causally or historically to physical or mental injuries relevant to issues necessary to administer my workers' compensation claim to BWC, the Industrial Commission of Ohio, the employer listed in the claim, that employer's managed care organization, any authorized representatives, and the Ohio Rehabilitation Services Commission. In addition, when you make any request to BWC, you grant us permission to access your confidential personal information to respond.
E-signature privacy information
Providing information to BWC is your choice. When you update information on this Web site or use the electronic signature function, you agree that the information you provide is accurate and complete to the best of your knowledge.
If you are willing to provide the requested information over this Web site, enter your initials in the box and check to create an electronic signature.
Electronic signature
An electronic signature is equivalent to your handwritten signature. It also acknowledges that you have read and understand the following warning statements.
-
About Information You Give Us
When you submit sensitive information over the Web site, that information is encrypted and protected by a secured socket layer (SSL). -
About Information You Receive
It is your responsibility to use the information you receive from this Web site for its intended purposes. -
Release of Information
Injured worker benefit application and medical release
When you submit a First Report of Injury, Occupational Disease or Death (FROI), you are filing a claim for work-related injuries. An electronic signature from the injured worker, his or her authorized representative or delegate authorizes any medical provider who attends to, treats or examines the injured worker in regards to the related workers' compensation claim to release all medical, psychological, and/or psychiatric information to BWC, the Industrial Commission of Ohio, the employer listed in the claim, that employer's managed care organization (MCO), and any authorized representatives.
-
Fraud Warning
Any person or entity, whose purpose is to defraud or who knows that a person is facilitating a fraud, obtains or attempts to obtain compensation or payment from BWC, an employer, or an MCO, by knowingly (1) misrepresenting or concealing a fact, (2) making a false statement, or (3) accepting compensation or payment to which he/she is not entitled, may be subject to repayment to BWC of all funds that have been overpaid, civil remedies, and/or felony criminal prosecution for fraud or other offenses. If you are working, you are not entitled to non-statutory permanent total, temporary total, non-working wage loss, or living maintenance disability benefits. -
Employer fraud warning
As an employer in the state of Ohio you are required to secure and maintain workers' compensation coverage with BWC or be granted self-insured status. Any person or entity who knowingly misrepresents the number or classification of employees or conceals a fact, makes a false statement, falsifies coverage, or makes any other attempt to avoid securing and maintaining coverage, or paying premiums or assessments in full, may be subject to repayment of funds due, administrative penalties, and/or criminal prosecution.
InjuryReport
Documentation
| FileName | Document Type | Description | Remove |
|---|---|---|---|
| test.jpg | test | test |
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