First Report of an Injury, Occupational Disease or Death

Warning: Any person who obtains compensation from BWC or self-insuring employers by: knowingly misrepresenting or concealing facts, making false statements, or accepting compensation to which he/she is not entitled, is subject to felony criminal prosecution for fraud. (R.C. 2913.48)

For faster service, complete as much of all three sections of this form as possible.

Injured Worker and Injury/Disease/Death Information

Last Name *

First Name *

Social Security # *

Sex

Male Female

Date of Birth *

Marital Status

Single Married Divorced Separated Widowed

# of Dependents *

Home Mailing Address *

City *

State * *

9-Digit Zip Code * *

Country *

Department

Wage Rate *

Wage Per

Hour Month Week
Year Other

If other, (please specify)

What days do you usually work?

Sun Mon Tue Wed Thu Fri Sat

Start Time *

End Time *

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

Yes No

Occupation or Job Title

Employer Name *

Was the injured employee hired through a temp agency?

Yes No

Temp Agency Name

Mailing Address *

City *

State * *

9-Digit Zip Code * *

County

Location, if different from mailing address

City

State *

9-Digit Zip Code *

On employer's premises?

Yes No

If no:

Accident Location (Street)

City

State *

Date of Injury/Disease * *

Time of Injury *

Date of Death (if fatal) *

Date Employer Notified *

Time Employee Began Work *

Date Last Worked *

Date Returned to Work *

Was part of a workday missed due to the injury?

Yes No

Number of hours scheduled the week of injury *

Date Hired *

State Where Hired *

State Where Supervised *

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

Type of Injury/Disease and Part(s) of Body Affected (For example: sprain lower left back etc.) *

Benefit application release of information — I am applying for a claim under the Ohio Bureau of Workers’ Compensation Act for work-related injuries that I did not inflict. I affirm that I elect to receive compensation and benefits under Ohio's workers’ compensation laws for my claim, and I waive and release my right to file for and receive compensation and benefits under the laws of any other state for this claim. I request payment for compensation and/ or medical benefits as allowable, and authorize direct payment to my medical providers. I permit and authorize any provider who attends, treats or examines me, the Ohio State Board of Pharmacy, the Ohio Department of Job and Family Services and the Ohio Rehabilitation Services Commission to release medical, psychological, psychiatric, pharmaceutical, vocational and social information. I understand this may include personally identifying information that is casually or historically related to my physical or mental injuries relevant to issues necessary for the administration of my claim to BWC, the Industrial Commission of Ohio, the employer in this claim, the employer’s managed care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim. Proper administration of the present claim may require BWC to share claims information with the employers of record (or their authorized representatives) and/or my authorized representative for any and all such previous or future claims. The released claims information may include any record maintained in my claim files.

Injured Worker Signature

Date *

E-mail Address *

Tel. Number *

Work Number *

Treatment Information

Health-Care Office/Facility name

Physician/Health-Care Provider

Tel. Number *

Fax Number *

Initial Treatment Date *

Street Address

City

State *

9-Digit Zip Code *

Diagnosis(es), including 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

E Code

Health-Care Provider Signature

11-Digit BWC PEACH Number *

Date *

Employer Information

Policy Number * *

Employer is Self-Insuring

Yes No

Injured Worker is Owner/Partner/Member of Firm

Yes No

Tel. Number *

Fax Number *

E-mail Address *

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 following:

Treatment Site

Street Address

City

State *

9-Digit Zip Code *

Certification - The employer certifies that the facts in this application are correct and valid. Rejection - The employer rejects the validity of this claim for the reason(s) listed: Clarification (SI Only) - The employer clarifies and allows the claim for the condition(s) listed:

If clarification, the type of claim is:

Medical Only Lost Time

Employer Signature and Title

Date *

OSHA Case Number