Data Management Forms
Claim Reporting Forms
FROI Instructions
First Report of Injury (FROI)
Used to report the occurrence of a workplace injury or occupational disease in a three stage process:
- An injured worker reports a workplace injury or occupational disease to their employer,
- The employer advances this information to their insurer or adjuster,
- The insurer or adjuster reports all claim data to the Montana Department of Labor and Industry
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.
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.
Electronic Data Interchange (EDI) Forms
Used by insurers and adjusters as a quick, efficient method of communicating data to the Department.
