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Workers' Comp First Report of Injury

Workers' comp First Report of Injury (FROI) — state-required filing within 24-72 hr.

Start free — included with every suite See it in MangoApps

14 days free, $0 today — Forms comes with every suite.

Rolled out to every employee at AutoZone (125,000), PetSmart (50,000+), A.S. Watson and Raley's (20,000) — and at larger retailers we are not permitted to name.

What's inside this template

Employee

  • Employee full name (required)
  • Date of birth (required)
  • SSN (last 4) (required)
  • Job title (required)
  • Hire date (required)
  • Average weekly wage (required)

Incident

  • Date and time of injury (required)
  • Specific location (required)
  • What was the employee doing? (required)
  • How did the injury occur? (required)
  • What part of the body was injured? (required)
  • Type of injury (required)

Medical Treatment

  • Initial treatment given (location)
  • Medical provider name
  • Hospitalized?
  • Date of return to work (or expected)

Reporter

  • Reporter name and title (required)
  • Reporter signature (required)
  • Date filed (required)

Common use cases

Workers' comp claim initiation
Insurance carrier notice
State agency filing

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Ready to use this template?

Workers' Comp First Report of Injury runs on a platform app included with every MangoApps plan — pick a suite and it comes along.

Start free — included with every suite

Rolled out to every employee at AutoZone (125,000), PetSmart (50,000+), A.S. Watson and Raley's (20,000) — and at larger retailers we are not permitted to name.