The forms listed below are those commonly used in the Data Management Unit functions of the workers' compensation system.
Claim Reporting Forms
First Report on Injury (FROI)
- 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
Subsequent Report of Injury (SROI)
Used by insurer/adjuster to report on-going claim data to the Department.
Request for Jurisdiction Assigned Number (JAN)
Used by a TPA when an injured worker's SSN is not available.
Notice Entry Forms
The purpose of this agreement is to provide access for a claim administrator or insurer and/or an insurer’s designated agent to the Notice Entry system for entering 14-day notices, Denials and Reservation of Rights.
Notice Entry Access Form
EDI Proof of Coverage Reporting Notice Entry Forms
The forms below have Montana specific information for EDI POC data elements based on IAIABC standards of POC Release 3.0.
POC Event Table -The Event Table will provide trigger criteria for each triplicate code. The table also provides the timelines for when each type of transaction should be sent based on the event that is being triggered.
POC Element Requirement Table - The Element Requirement Table contains data elements that Montana accepts. This table includes the severity of each element for each triplicate code as well as conditional requirements.
POC Edit Matrix Table -The Edit Matrix Table includes applied editing based on the IAIABC standards and Montana’s POC data requirements.
Insurers/Third Party Administrators Reporting Forms
Third Party Administrator/Adjuster Change Form
Used to report changes in adjuster, claim administrator, or third party administrators.
Third Party Administrator Profile
Used for adding new Third Party Administrators (TPA) and for changes to contact information for existing TPAs.
Electronic Data Interchange (EDI) Forms
Used by insurers and adjusters as a quick, efficient method of communicating data to the Department.
Electronic Prior Claims (EPC) Forms
Electronic Prior Claims (EPC) History Access Agreement
Used by an insurer to obtain access to the EPC system in order to obtain prior claim history on their claimants.
EPC Carrier Assignments
Used by an Insurer or Claim Administrator to list the carriers for which they are the "adjuster at risk."