Get the free First Report of Injury Form (FROI) - nitmn

MN Department of Labor and Industry Workers Compensation Division PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5032 or 1-800-342-5354 Fax: (651) 284-5731 First Report of Injury See Instructions

How to fill out first report of injury

How to fill out first report of injury:

1. Obtain the necessary forms: Begin by obtaining the First Report of Injury form from your employer or workers' compensation department. This form will typically require you to provide information about the incident, as well as your personal details.
2. Provide accurate incident details: Start by describing how the injury occurred, including the date, time, and location. Include a detailed explanation of the events leading up to the injury, any contributing factors, and any witnesses present. Be as specific as possible to ensure an accurate account.
3. Describe the nature of the injury: Clearly state the type of injury you sustained, whether it is a sprain, fracture, laceration, or any other type. Include information about the affected body part, the severity of the injury, and any immediate treatment received, such as first aid or emergency medical care.
4. Include medical information: Provide information about the healthcare provider who treated you, including their name and contact details. If you were transported to a hospital, include the name and address of the facility. Additionally, mention the dates of any subsequent medical visits related to the injury.
5. Provide personal information: Fill in your personal details accurately, including your full name, address, phone number, and email address. If you have workers' compensation insurance, include your policy number. You may also need to provide information about your job title, department, and supervisor.
6. Submit the completed form: Once you have filled out all the necessary information, submit the completed First Report of Injury form to your employer or the designated department responsible for handling workers' compensation claims. Keep a copy of the form for your records.

Who needs the first report of injury?

The first report of injury is needed by several parties, including:

1. Employer: Your employer requires this report to initiate the workers' compensation process, ensuring that your injury is officially documented and investigated.
2. Workers' Compensation Department: The workers' compensation department handles the processing of your claim, including determining your eligibility for benefits and managing any medical treatment required.
3. Insurance Provider: If your employer has workers' compensation insurance, the insurance provider needs the first report of injury to evaluate your claim and make appropriate decisions regarding coverage and compensation.
4. Healthcare Providers: Medical providers may also request a copy of the first report of injury to verify the details of the incident and help determine the appropriate treatment and billing.

Remember, it is essential to submit the first report of injury promptly after the incident to ensure a smooth claims process and access to the necessary benefits and medical treatment.

For pdfFiller’s FAQs

What is first report of injury?

The first report of injury is a document that provides details about an employee's work-related injury or illness.

Who is required to file first report of injury?

Employers are required to file the first report of injury when an employee suffers a work-related injury or illness.

How to fill out first report of injury?

The first report of injury should be filled out by including information about the employee, details of the injury or illness, and any medical treatment provided.

What is the purpose of first report of injury?

The purpose of the first report of injury is to document and track work-related injuries and illnesses, as well as to ensure that employees receive the proper medical care and benefits.

What information must be reported on first report of injury?

The first report of injury must include the employee's name, date of injury, description of the injury, location where the injury occurred, and any medical treatment received.

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