Employers Efroi Worksheet

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EMPLOYERS eFROI WORKSHEET
eFROI System – all fields marked with an asterisk are required
* Company Name:________________________________________________________
*Company Address:_______________________________________________________
*NYSIF Policy Number ___________________ *Date of injury/Illness______________________
*Does injured worker have a SSN? Yes____ No____
**If Yes - Injured Employee’s Social Security Number_______________________
*First Name:_____________________________*Last Name:____________________________
*Date of Birth:___________________________
Employee Address
*Address Line 1:_________________________________________________________________
*City: __________________________________ *State: _________________________________
*Zip Code: _______________________________ *Country: ________________________________
*Gender:
Male______ Female______
Telephone Number: ________________________
Employee Injury or Illness
*Date of Injury________________________________
*Employee began work at ____ am ____ pm
*Time of injury ____ am ____ pm
*Has employee given you notice of injury/illness
Yes____ No____
*If yes notice was given to:
First Name: ________________________
Last Name: ________________________
*If yes, was notice given orally or in writing or both Orally ____ In writing ____ or both ____
*Date notice provided______________________
*Did you give claimant a “claimant information packet”? Yes____ No____ *If Yes date ______________

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