FIRST REPORTS OF INJURY MAKING THEM WORK FOR YOU

PURPOSE OF THE FIRST REPORT OF INJURY  Document required by the State of Alabama Workers Compensation Division in the event of an accident  To ensure proper detailed reporting of an accident  Tracking of accidents by the State and rating bureaus for purposes of loss control, premium, and statistics

COMMON PROBLEMS IN COMPLETION OF FROI  Inaccurate/incomplete responses to requested information  Delayed submission of forms to workers compensation carrier  Lack of detailed responses in regards to the injury

NEW FIRST REPORT OF INJURY FORM

FILLING OUT THE FROI  The FROI is broken into six sections CLAIM REFERENCE – Items 1 thru 3 CLAIM REFERENCE – Items 1 thru 3 EMPLOYER – Items 4 thru 17 EMPLOYER – Items 4 thru 17 INSURER/FILING OFFICE – Items 18 thru 27 INSURER/FILING OFFICE – Items 18 thru 27 EMPLOYEE/WAGES – Items 28 thru 50 EMPLOYEE/WAGES – Items 28 thru 50 INJURY/TREATMENT – Items 51 thru 76 INJURY/TREATMENT – Items 51 thru 76 OTHER – Items 77 thru 81 OTHER – Items 77 thru 81

CLAIM REFERENCE  ITEM #1 – This number is assigned by the member  ITEM #2 – This number is assigned by Municipal Workers Compensation Fund, Inc.  ITEM #3 – This number is assigned by OSHA

EMPLOYER  ITEMS # 4 THRU 9 – Street address of member  ITEMS # 10 THRU 14 – Mailing address of member if different from street address  ITEM #15 – Member’s Federal Tax ID Number

EMPLOYER CONTINUED  ITEM #16 – Member’s State Unemployment Compensation account number (Example )  ITEM # 17 – North American Industry Classification System (NAICS) number (Housing Authority ) (All others )

INSURER/FILING OFFICE  ITEM # 18 – Municipal Workers Compensation Fund, Inc. (MWCF, Inc.)  ITEM # 19 – MWCF Federal Tax ID Number – to be filled out by MRM  ITEM # 20 – Check the Group Fund Box and list your Group Fund Number ( ) – SEE STATE COI ON NEXT SLIDE  ITEM # 21 – Millennium Risk Managers, LLC (MRM)

SAMPLE STATE COI

INSURER/FILING OFFICE CONT’D  ITEM # 21a –  ITEM # 22 – P.O. Box  ITEM # 23 – (205)  ITEM # 24 – Birmingham  ITEM # 25 – AL  ITEM # 26 –  ITEM # 27 – Millennium Risk Managers, LLC Federal Tax ID Number – to be filled out by MRM

EMPLOYEE/WAGES  ITEM # 28 – Employee First Name  ITEM # 29 – Employee Middle Name  ITEM # 30 – Employee Last Name  ITEM # 31 – Employee Last Name Suffix  ITEM # 32 – Employee ID Number  ITEM # 33 – Type of ID supplied, check appropriate box

EMPLOYEE/WAGES CONT’D  ITEM # 34 – Employee Mailing Address 1  ITEM # 35 – Employee Mailing Address 2  ITEM # 36 – Employee Address City  ITEM # 37 – Employee Address State  ITEM # 38 – Employee Address Zip Code

EMPLOYEE/WAGES CONT’D  ITEM # 39 – Employee Telephone Number  ITEM # 40 – Check Appropriate Employee Gender Box  ITEM # 41 – Employee Date of Birth  ITEM # 42 – Employee Number of Dependents  ITEM # 43 – Employee Marital Status – Check Appropriate Box

EMPLOYEE/WAGES CONT’D  ITEM # 44 – Employee Date Hired  ITEM # 45 – Employee Occupation at Time of Injury  ITEM# 46 – Number of Days Employee Works Per Week  ITEM # 47 – Employee Current Wages  ITEM # 48 – Mark Appropriate Wage Payment Box

EMPLOYEE/WAGES CONT’D  ITEM # 49 – Did Employee Receive Full Pay for Day of Injury – Mark Appropriate Box  ITEM # 50 – Did Salary Continue – Mark Appropriate Box

INJURY/TREATMENT  ITEM # 51 – Date of Injury  ITEM # 52 – Time of Injury – list time and mark appropriate box below. If time is unknown, mark the unk box (AM/PM/UNK)  ITEM # 53 – Time Employee Began Work on the Day of the Injury – list the time and mark the approprate box below (AM/PM)

INJURY/TREATMENT CONT’D  ITEM # 54 – List the Date the Disability Began  ITEM # 55 – Date of Death  ITEM # 56 – List the address of the location where the injury actually occurred  ITEM #57 – City of location where the injury actually occurred

INJURY/TREATMENT CONT’D  ITEM # 58 – State where the injury actually occurred  ITEM # 59 – Zip Code where the injury actually occurred  ITEM # 60 – County where the injury actually occurred  ITEM # 61 – Occurred on Employer’s Premises – Mark appropriate box

INJURY/TREATMENT CONT’D  ITEM # 62 – Date Employer Notified  ITEM # 63 – Describe what the employee was doing just before the incident and how the injury occurred – Give detailed description

INJURY/TREATMENT CONT’D  ITEM # 64 – Nature of Injury Code

INJURY/TREATMENT CONT’D  ITEM # 65 – Part of Body Code

INJURY/TREATMENT CONT’D  ITEM # 66 – Cause of Injury Code

INJURY/TREATMENT CONT’D  ITEM # 67 – Initial Treatment – Mark Appropriate Box  ITEM # 68 – List Name of Treatment Facility  ITEM # 69 – Treatment Facility Address  ITEM # 70 – Treatment Facility City  ITEM # 71 – Treatment Facility State

INJURY/TREATMENT CONT’D  ITEM # 72 – Treatment Facility Zip Code  ITEM # 73 – Name of Treating Physician  ITEM # 74 – Return to Work – Mark Appropriate Box (Yes or no)

INJURY/TREATMENT CONT’D  ITEM # 75 – If Employee has returned to work – list the date of return  ITEM # 76 – List time of return to work and mark appropriate AM/PM box

OTHER  ITEM # 77 – Date Injury Reported to Employer  ITEM # 78 – Preparer’s First Name  ITEM # 79 – Preparer’s Last Name  ITEM # 80 – Preparer’s Job Title  ITEM # 81 – Preparer’s Telephone Number PLEASE NOTE: PREPARER MUST BE DIFFERENT THAN INJURED

DOWNLOADING NEW FORM   DOWNLOADS  UNDER DOCUMENTS BY DIVISION CLICK ON WORKERS COMPENSATION  UNDER FORMS, CLICK ON WC FIRST REPORT OF INJURY (WC FORM 2 REV. 9/2006) REQUIRES MICROSOFT WORD  THERE IS ALSO A PDF VERSION BUT IT CANNOT BE FILLED ON YOUR PC, IT MUST BE PRINTED AND FILLED IN

SUBMITTING FROI FORMS  Four ways to file the First Report of Injury Fax - (205) Fax - (205) PREFERRED - - Phone Reporting – Phone Reporting – Mail - Millennium Risk Managers, LLC Mail - Millennium Risk Managers, LLC Post Office Box Post Office Box Birmingham, AL 35226

ELECTRONIC FILING  Electronic filing is no longer required; however, it is preferred  The State of Alabama originally was requiring electronic filing of the First Reports of Injury; however, this will now be done by MWCF and MRM via an upload of information to the State on a regular basis