Workers Compensation Forms

First Report of Injury (FROI)

FROI Instructions

FROI Form

  • Simply tab through the fields to complete the form
  • Used by an injured worker to report an injury or occupational disease to his/her employer
  • Used by an employer to report an injured worker's injury or occupational disease to the employer's insurer/adjuster
  • Used by an insurer/adjuster to report claim data to the Department

Settlement Forms

Petition for Settlement - Disputed Initial Comp & Checklist for Settlement Requirements
Used when initial compensability of a claim is denied. No recap sheet required.

Petition for Settlement - Injury/OD, Medical Benefits Reserved


Petition for Settlement - Injury/OD, Medical Closed on an Accepted Claim
Used when settlement of medical is in best interest of parties or settling wage loss entitlement (other than Perm Total) and settlement of medical is in best interest of parties.


Petition for Settlement - Injury/OD, Disputed Medical Closed
Used when settling wage loss entitlement & disputed perm total benefits and disputed medical benefits.


Petition for Settlement - PTD, Injury/OD Medical Benefits Reserved
Used when settling perm total benefits and medical benefits are reserved.


Petition for Settlement - PTD, Injury/OD Medical Closed on an Accepted Claim
Used when settling perm total benefits and settlement of medical is in best interest of parties.



Petition for Advance & Checklist for Advance Requirements

Other Forms