Workers Compensation Forms

FROI Online Form

FROI Printable Form

FROI Instructions

• 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

Formulario FROI

Instruciones FROI

• Simplemente navegue por los campos para completar el formulario
• Utilizado por un trabajador lesionado para informar una lesión o enfermedad ocupacional a su empleador
• Utilizado por un empleador para informar la lesión o enfermedad ocupacional de un trabajador lesionado al asegurador/ajustador del empleador
• Utilizado por un asegurador/ajustador para informar datos de reclamos al Departamento

Used when initial compensability of a claim is denied. No recap sheet required.

Petition for Settlement - Injury/OD, Medical Benefits Reserved

• Petition Instructions
• Recap Sheet
• Recap Sheet Instructions

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 Instructions
• Recap Sheet
• Recap Sheet Instructions
• Summary of Settlement of Medical Benefits
• Summary Instructions

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

• Petition Instructions
• Recap Sheet
• Recap Sheet Instructions

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

• Petition Instructions
• Recap Sheet
• Recap Sheet Instructions

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 Instructions
• Recap Sheet
• Recap Sheet Instructions
• Summary of Settlement of Medical Benefits
• Summary Instructions

Petition for Advance & Checklist for Advance Requirements

• Beneficiaries' Claim for Compensation
• Attorney Retainer Document
  Used by an attorney to formalize fee contract with an injured worker.