First Report of an Injury, Occupational Disease or Death

Please provide the following information:

For the Injured Worker:

*Last Name
*First Name
*Middle Initial
*Street Address
Address (cont.)
*City
*State/Province
*Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

*Date of Birth	-mm/dd/yy
*Sex	Male Female

*Social Security Number:

What is your normal Wage (Dollars per Hour/Day/Week, etc.)?

Your wages are paid per: Hour Week Month Year Other (explain in next box)

Other Wage Option (if explanation is needed).

Marital Status:

Single Married Divorced Separated Widowed Number of Dependents:

Occupation or Job Title:

Department:

What days of the week do you usually work?

Sunday     Monday     Tuesday    Wednesday
Thursday   Friday     Saturday   

Normal Start Time : -- hh:mm:ss am/pm Normal End Time : -- hh:mm:ss am/pm

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

YES NO   If YES, Please Explain:

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*Employer Name:   

Employer Mailing Address (number and street, city or town, state, ZIP code and county).

Employer 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 below.)

*Date of injury/disease:           -- mm/dd/yy  Time of injury: -- hh:mm:ss am/pm

If fatal, give date of death : -- mm/dd/yy Time employee began work:      -- hh:mm:ss am/pm

Date last worked:              -- mm/dd/yy  Date returned to work:              -- mm/dd/yy

Date Hired: -- mm/dd/yy State where hired: Date employer notified : -- mm/dd/yy

*Description of accident: (Describe the sequence of events that directly injured the employee, or caused the disease of death.)

*Type of injury/disease and part(s) of body affected: (For example: sprain of lower back)

 

Benefit application/medical release - I am applying for recognition of my claim under the Ohio Workers' Compensation Act for work-related injuries that I did not purposely inflict. I request payment for compensation and/or medical expenses as allowable. Direct payment(s) to the providers of any medical services are authorized. I understand that I am allowing any provider who attends to, treats or examines me to release all medical, psychological and/or psychiatric information that is causally or historically related to physical or mental injuries relevant to issues necessary to the administration of my workers' compensation claim to the Ohio Bureau of Workers' Compensation, the Industrial Commission of Ohio, the employer listed in this claim, that employer's managed care organization and any authorized representatives. I further authorize the Ohio Rehabilitation Services Commission to release information about my physical, mental, vocational and social conditions that is causally or historically related to physical or mental injuries relevant to issues necessary for the administration of my workers' compensation claim to the aforementioned parties.

Injured Worker Signature:

Today's Date                   -- mm/dd/yy

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Treatment Info

*Health-care provider name:

Health-care provider Address: (Street Address, City, State, ZIP code)

Health-care provider Telephone Number:

Health-care provider FAX:                     

Initial Treatment Date:                              -- mm/dd/yy

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

Health-care Provider Signature: -- mm/dd/yy

11-digit BWC provider number:   Today's Date: -- mm/dd/yy

Employer Info

Employer policy number:

Select any of the following options that apply: Employer is self-insuring Injured worker is owner/partner/member of firm
 

Employer Telephone Number: FAX:

E-mail Address:

Employer Federal ID number:

Manual number:                     

Was employee treated in an emergency room?             YES NO

Was employee hospitalized overnight 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 certifies that the facts in this application are correct and valid. YES NO

Rejection - The employer rejects the validity of this claim for the reason(s) listed below. YES (Explain in next section) NO (Employer accepts claim as valid)

Employer rejects the validity of this claim for the following reason(s):

(For self-insuring employers only) Clarification - The employer clarifies and allows the claim for the condition(s) below:

Medical Only  Lost Time     

Clarification Conditions:

Employer Signature and Title:

Today's Date:             -- mm/dd/yy

OSHA Case number: