Department of Labor and Industry

Data Management Forms

Data Management Unit Forms

 

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)

FROI Instructions

  • 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

Legal size form - recommended for those who wish to complete it long hand.
Letter size form - this form in WORD format for those who wish to complete it on their computer.

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.

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."

Medical Providers Billing Request Form
Used by a medical provider to obtain from the Department sufficient information to send an injured worker’s medical bill to the proper insurer or adjuster. (Used only when EPC access is not available)