Form Bwc-1101 - First Report Of An Injury, Occupational Disease Or Death - 2000
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1WARNING:
First Report of an
Any person who obtains compensation from
BWC or self-insuring employers by:
Injury, Occupational
Better Workers’ Compensation
knowingly misrepresenting or concealing facts,
Built with you in mind.
making false statements, or accepting compensation
Disease or Death
to which he/she is not entitled, is subject to felony
For faster service
criminal prosecution for fraud.
(R.C. 2913.48)
Complete as much of all four sections of this form as possible.T ype or print in black or blue ink.
Last Name, First Name, Middle Initial
Social Security Number
Marital Status
Date of Birth
Single
Home Mailing Address
Sex
Number of Dependents
Married
Male
Female
Divorced
Separated
City
State
9-digit ZIP Code
Country if different than U.S.A.
Department Name
Widowed
Wage Rate
What days of the week do you usually work?
Regular Work Hours
Hour
Month
Week
$ ____________________ Per:
Sun
Mon
Tues
Wed
Thur
Fri
Sat
Year
Other ___________
From_______ To_______
Have you been offered or do you expect to receive payment for this claim from anyone
Occupation or Job Title
other than the Ohio Bureau of Workers’ Compensation or the employer?
YES
NO
Benefit Application/Medical Release
I am applying for recognition of my claim under the Ohio
to release all medical, psychological, and/or psychiatric information
Telephone Number
Work Number
Workers’ Compensation Act for work-related injuries that I did
that is related to my workers’ compensation claim to the Ohio
not purposely inflict. I request payment for compensation and/or
Bureau of Workers’ Compensation, the Industrial Commission
Injured Worker Signature
Date
medical expenses as allowable. Direct payment(s) to the providers
of Ohio, the employer listed in this claim, that employer’s
of any medical services are authorized. I understand that I am
managed care organization, and any authorized representatives.
allowing any provider who attends to, treats or examines me
Date of Injury/Disease
Date Last Worked
Date Returned to Work
Time of Injury
If fatal, give date of death
__________
AM
PM
Date Hired
State Where Hired
Date Employer Notified
Accident Location (street address)
City
State
Was place of accident or exposure
YES
NO
on employer’s premises?
Description of Accident (Describe the sequence of events that
Type of Injury/Disease and Part(s) of Body Affected
directly injured the employee, or caused the disease or death)
(For example: sprain of lower left back, etc.)
Telephone Number
Fax Number
Initial Treatment Date
Physician/Health–Care Provider Name
(
)
(
)
City
State
9-digit ZIP Code
Street Address
Diagnosis(es): Include ICD-9 Code(s)
Will this incident cause the injured worker to miss
eight or more days of work?
YES
NO
Is this injury causally related to the
industrial incident?
YES
NO
Provider Signature
BWC Provider Number
Date
Employer Name
Policy Number
Employer is Self-Insuring
Injured Worker is Owner/Partner/Member of Firm
Mailing Address (Number and Street, City or Town, State, and ZIP Code)
County
Location, if different from mailing address
Manual Number
Telephone Number
Fax Number
Federal ID number
(
)
(
)
FOR SELF-INSURING EMPLOYERS ONLY:
CERTIFICATION - The employer
REJECTION - The employer
certifies that the facts in this
rejects the validity of this claim
CLARIFICATION - The employer clarifies
application are correct and valid.
for the following reason(s) below:
and allows the claim for the condition(s) below:
Date
Employer Signature and Title
OSHA Case Number
FROI-1 (Combines C-1, C-2, C-3, C-6, C-50, C-51, OD-1, OD-1-22)
BWC-1101 (Rev. April 3, 2000)
This form meets OSHA 101 requirements.
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