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First Report of an Injury,

Occupational Disease or Death

This form can be completed and submitted online at

Report your injury by completing all three sections of this form

Complete as much of all three sections of this

If you do not know your employer's MCO, contact

form as possible to reduce the time necessary in

BWC at 1-800-644-6292 and follow the prompts,

or use the MCO on BWC's Web site at www.

determining the claim. If this form is completed

bwc.ohio.gov.

by the injured worker at the first visit to a medical

provider, the injured worker may give the FROI

If you are unable to determine your MCO, mail

to the provider to complete the treatment

or fax this form to the BWC customer service

information section. T he provider can then submit

the FROI to the MCO.

office closest to your home. For information on

your local customer service office, please visit

Deliver, mail or fax the completed document to

., or call 1-800-644-6292.

your employer or your employer's managed care

organization (MCO).

Injured workers employed by a self-insuring employer

• Complete this form and give to your employer.

• Your employer should be able to tell you if he or she is a self-insuring employer.

• If your employer is self-insuring and you file this information with BWC, processing delays may occur.

For assistance in completing this form, call your BWC customer service office Monday through Friday, 8 a.m. – 5 p.m.

Cambridge

Dayton

Mansfield

61501 Southgate Road

3401 Park Center Drive, Suite 100

240 Tappan Drive, N., Suite A

Cambridge, OH 43725-9114

Dayton, OH 45414-2577

Ontario, OH 44906-1366

Phone: 740-435-4200

Phone: 937-264-5000

Phone: 419-747-4090

Fax: 866-281-9351

Fax: 866-281-9356

Fax: 866-336-8350

Canton

Garfield Heights

Portsmouth

339 E. Maple St., Suite 200

4800 E. 131 St., Suite A

1005 Fourth St.

North Canton, OH 44720-2593

Garfield Heights, OH 44105-7132

Portsmouth, OH 45662-4315

Phone: 330-438-0638

Phone: 216-584-0100

Phone: 740-353-2187

Toll free: 800-713-0991

Toll free: 800-224-6446

Fax: 866-336-8353

Fax: 866-281-9352

Fax: 866-457-0590

Toledo

P .O. Box 794

Cleveland

Cincinnati–Governor’s Hill

615 Superior Ave. W.

8650 Governor’s Hill Drive

1 Government Center, Suite 1136

Cleveland, OH 44113-1889

Cincinnati, OH 45249-1369

Toledo, OH 43697-0794

Phone: 216-787-3050

Phone: 513-583-4400

Phone: 419-245-2700

Toll free: 800-821-7075

Fax: 866-281-9357

Fax: 866-457-0594

Fax: 866-336-8345

Lima

Youngstown

2025 E. Fourth St.

242 Federal Plaza, W., Suite 200

Columbus

30 W. Spring St.

Lima, OH 45804-4101

Youngstown, OH 44503-1206

Columbus, OH 43215-2256

Phone: 419-227-3127

Phone: 330-797-5500

Phone: 614-728-5416

Toll free: 888-419-3127

Toll free: 800-551-6446

Fax: 866-336-8352

Fax: 866-336-8346

Fax: 866-457-0596

First Report Of An Injury, Occupational Disease Or Death - Ohio Bureau Of Workers Compensation

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