Required Information for FROI

If you are an Employer:

• Injured Worker Name
• Injured Worker Social Security Number
• Injured Worker Mailing Address
• Injured Worker Home or Work Phone Number
• Date of Birth
• Date of Injury/Disease
• Gender
• Occupation or Job title
• Description of Accident
• Type of Injury/Disease and Part(s) of Body Affected
• Employer Policy Number (lookup function provided)
• Place of Accident or Exposure on Employer's Premises
• Date Hired
• Type of Injury/Disease and Part(s) of Body Affected
• Date Employer Notified