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First Report of Injury

* denotes required fields

Your Information

Your Name:*


Date:*


Email Address:*



Claimant/Employee Information

Name:*


D.O.B.:*


SSN:*


Sex:* Male Female

Home Address:*


City:*


State:*


Zip:*


Phone #:


Job Title:*


Date Hired:



Employer Information:

Employer:*


Nature of Business:


Mailing Address:


Physical Address (if different):


Employer Phone #:*


WC Policy #:



Payroll Information:

Average Weekly Wage:*

Did the employee receive lodging or tips in addition to pay?
Yes
No

If yes, describe:

Employees Job Was (check one): 
Full Time
Part Time
Seasonal
Volunteer

Work Week (days worked):*
M
T
W
TH
F
SA
SU

Was the employee paid for a full day on the day of the injury/illness?* Yes   No


Accident Information:

Date of Accident:*


Time of Accident:
  AM PM

Time of day employee began to work on date of injury:
  AM PM

Has the employee given you notice of injury/illness?*
Yes
No

Where did the accident occur?*


Was this location where the employee normally worked?*
Yes
No

If No, Why was employee there?


Employee's Supervisor:


Did Supervisor see injury happen?
Yes
No
Unknown

Did anyone else see the injury happen?
Yes
No
Unknown

If yes, name of witness:


What was employee doing when injured (be specific)?*


What body part was affected?*


Was an object (e.g. forklift, hammer, acid?) involved in injury/illness?
Yes No

If Yes, What was it?


Was the injury the result of the use or operation of a licensed motor vehicle? Yes No

If Yes:
Employer's vehicle
Employee's vehicle
Other vehicle

License plate number (if known)


Auto Insurance information:



Accident Information (continued)

Did the injury/illness result in the employee's death?
Yes
No

If Yes, what was the date of death?


Are you disputing the accident? If so, why?


Have you given the employee a Claimant Information Packet?
Yes
No

If yes, when was it given?



Medical Treatment Information:

Did the employee receive medical treatment?*
Yes
No
Unknown

Where did the employee receive first medical treatment for this injury/illness?
Onsite
Doctor's office
Emergency Room
Clinic/Hospital/Urgent Care
Hospital stay over 24 hours
Unknown

Who treated the employee and where?

Doctor Name:


Hospital/Clinic Name (if applicable):


Address:


Telephone:


Is the employee still being treated for this injury/illness?
Yes
No
Unknown

If Yes, name and address of treating doctor(s):


To your knowledge, did the employee have another work-related injury to the same body part or a similar illness while working for you?
Yes
No
Unknown



Return to Work Information:

Did the employee stop work because of his/her injury/illness?*
Yes
No

Did the employee lose more than one day or one shift because of his/her injury/illness?*
Yes
No
If Yes:
What was the last date the employee worked?


What was the first scheduled work day or work shift they missed after the accident?


When did the employer become aware that the employee's lost time was due to their injury/illness?


Did the employee, or is the employee anticipated to, lose more than one week of work?
Yes
No

Light duty available?
Yes
No

Is claimant/employee back to work?*
Yes
No   
If yes, date of return to work:

Did you continue to pay the employee after the injury/illness?*
Yes
No

Full Pay?
Yes
No

If No, average gross earnings?


Comments:


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Please call 1-888-785-7755 ext. 8813 or ext. 8815 with any questions about this form or your claim.

We have enclosed the following updated information for all GCG Clients:
First Report of Injury (FROI) Instructions and (FROI) Filing Guide

This information will answer your questions concerning the reporting of claims.

Please use the attached Filing Guide to ensure that your claims are properly reported & processed in a timely manner.

If you have any questions, please reference the attached (FROI) instructions.

Users should be GCG Risk Management clients or in the process of becoming a client.