Workers' Comp — FROI Intake

First Report of Injury · Sec.10 FNOL, workers' comp variant

First Report of Injury

Employee Name *

Employee ID

Employer / Site *

Date/Time of Injury *

Body Part *

Cause Code *

Jurisdiction *

Witness(es)

Description of Injury *

Supervisor sign-off confirmed by

Processing FROI...

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FROI Auto Functions

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Recently Submitted — Workers' Comp

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