First Report Of Injury Page 2
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4Pennsylvania
ELECTRONIC DATA
INTERCHANGE
DEPARTMENT OF LABOR & INDUSTRY
BUREAU OF WORKERS' COMPENSATION
First Report of Injury
Transaction Title: (e.g. FROI)
Jurisdictional Claim Number: (e,g.CLM-2012021312345)
Transaction Type: (e.g. Denial 04)
Date Transaction Submitted to BWC: May 8 2012 01:30PM
Employee Information
First Name:
Middle Name:
Last Name:
Last Name Suffix:
Employee ID:
ID Type:
Date of Birth:
Date of Death:
Number of Dependents:
Employee Marital Status Code:
Mailing City:
Mailing State Code:
Mailing Postal Code:
Gender Code:
Mailing Primary Address:
Mailing Secondary Address:
Mailing Country Code:
Phone Number:
Date Of Hire:
Occupation Description:
Claim Information
Jurisdiction Claim Number:
Jurisdiction:
Initial Date Disability Began:
Claim Type Code:
Type of Loss:
Death Result of Injury Code:
Claim Status Code:
Late Reason Code:
Accident Site County/Parish:
Initial Return to Work Date:
Initial Date Last Day Worked:
Employment Status Code:
Employer Paid Salary In Lieu of Compensation Indicator:
Date Employer Had Knowledge of Date of Disability:
Return to Work Type Code:
Injury Information
Date of Injury:
Nature of Injury Code:
Time of Injury:
Claim Transaction Details - FROI (LIBC-344)
LIBC-90 REV 01-13 (Page 1)
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