Gawsh FROI System - Create FROI report

Please tell us about yourself

Your name:
Telephone number where you can be reached:
If this was a real incident report, a claims representative from [your insurance carrier] may need to contact you at this number to discuss the incident, any benefits that may be due, medical or other treatment, or whatever.

Your job description:

Agent/claims adjuster
Claimant
Employer representative
Medical provider

Please tell us where the claim happened, or if the federal workers compensation rules would apply
	State jurisdiction:	Type a state abbreviation, or click on one of these:	Federal jurisdiction:
If you change the state here, the system will change the fields displayed on other tabs, to reflect the actual data reporting requirements of the various states. For example, there are fields on the 'Treatment' tab for a hospital name and address, that are displayed only if the state is CA or NY. Take a look at the 'Treatment' tab now, then return to this tab and change the state to some other state, then check the 'Treatment' tab again and see how the 'hospital' fields mysteriously disappeared.

Please tell us if we should send you a copy of the completed report, and how we should send it to you

Please send me a printed copy of this report, via postal mail, to this address:

Address line 1
Address line 2
City/state/zip		Type a state abbreviation, or click on one of these:

Please fax me a copy of this report

Fax number:

Please e-mail me a copy of this report

Email address:

Again, this is just a demonstration system. We are not really going to print and mail (or fax, or email) you a copy of whatever you enter here. Sorry.

Please tell us about the employer

Employer name:
Address (line 1):
Address (continued):
City:
State:	Type a state abbreviation, or click on one of these:
Postal (zip) code:
Employer nature of business:

Employer FEIN:
Employer is self-insured:
Policy number:
Employer contact business phone number:
Employer UI (unemployment insurance) number:
Type of employer :

Please tell us about the injured worker

Last name:
First name:
Middle name/initial:
Address (line 1):
Address (continued):
City:
State:	Type a state abbreviation, or click on one of these:
Postal (zip) code:
Phone number:
Occupation description:

Employee SSN:

Date of birth:

(mm)	(dd)	(yyyy)

Gender:

Marital status:

Number of dependents:

When did the injury occur?

Date of injury:

(mm)	(dd)	(yyyy)

Time of injury:

Time employee began work:

Date employer had knowledge of the injury:

(mm)	(dd)	(yyyy)

Initial date last day worked:

(mm)	(dd)	(yyyy)

Date employee was provided claim form:

(mm)	(dd)	(yyyy)

Describe what happened

Accident/injury description narrative:
Equipment, materials and chemicals in use at time of incident:
Specific activity being performed at time of incident:

Where did the incident occur?

Accident site narrative:

Either fill in the 'narrative' above, or the specific address below; you don't have to fill in both

County:
Street:
City:
State:	Type a state abbreviation, or click on one of these:

Was this the employer's premises:
Employer location code:
Department where event occurred:

Please describe the incident further ...

Nature of injury:
Part of body injured:
Cause of injury:
Were any other workers injured:

What was the result of the incident?

Initial date disability began:

(mm)	(dd)	(yyyy)

If the employee died, please enter the date of death:

(mm)	(dd)	(yyyy)

If the employee has already returned to work, enter the initial return to work date:

(mm)	(dd)	(yyyy)

Did the worker receive medical attention?

Initial medical provider's name:
Address (line 1):
Address (continued):
City:
State:	Type a state abbreviation, or click on one of these:
Postal (zip) code:

Hospital name:
Address (line 1):
Address (continued):
City:
State:	Type a state abbreviation, or click on one of these:
Postal (zip) code:
Phone number:

Was the worker hospitalized overnight :
Was the worker treated in an emergency room :

Please specify the worker's wages and/or other compensation prior to the incident

Average wage:
Wage period:
Number of days worked per week:
Other payments not reported as wages/salary :

Employment status code:
Manual classification code:
Number of hours worked per day:
Number of hours worked per week: