Workers Comp

Claim Number:
Tear off this sheet and return completed form to your employers managed care organization (MCO) or to your local BWC customer service office.
Better Workers Compensation
Built with you in mind.
First Report of an Injury, Occupational Disease or Death

Social Security number
WARNING:
Any person who obtains compensation from BWC or self-insuring employers by: knowingly misrepresenting or concealing facts, making false statements, or accepting compensation to which he/she is not entitled, is subject to felony criminal prosecution for fraud. (R.C. 2913.48)
Marital status Single s Married Divorced Separated Widowed Date of birth
09/26/72
Last name, first name, middle initial

Hintze, Brandi M.
123-45-6789
Sex State
OH
s
Home mailing address

1796 Indian Wood Circle
Number of dependents
1
City
Maumee
9-digit ZIP code

43537
s Female Male Country if different from USA
Department name
Asset Protection
Injured Worker and Injury/Disease/Death Info.
What days of the week do you usually work? Week Hour Month $ Per: Year Other Sun Mon Tues Wed Thur Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau of Workers' Compensation? YES s NO If yes, please explain. Employer name Wage rate
500.00
Best Buy
Regular work hours 9 am To Fri Sat From Occupation or job title

Asset Protection Lead
9 pm
Mailing address (number and street, city or town, state, ZIP code and county)
10017 Fremont Pike Perrysburg, OH 43551
Location, if different from mailing address Was place of accident or exposure on employer's premises? s YES NO If no, give accident location, street address, city, state and ZIP code) Date of injury/disease Time of injury If fatal, give date of death 4:00 AM s PM 12/09/2012 Date hired
05/18/2007
Time employee 9:00 began work
State where hired

OH
Date last worked AM s PM 12/09/2012 Date employer notified

12/09/2012
Date returned to work

N/A
Description of accident (Describe the sequence of events that directly injured the employee, or caused the disease or death
Type of injury/disease and part(s) of body affected (For example: sprain of lower left back, etc.)
I observed via CCTV a white male adult approach our Beats Headphones display. He selected a Laceration to back of head pair and put them under his shirt. I maintained constant CCTV surveillance. The subject passed the last point of sale and I then attempted to apprehend him for the theft at the exit. He pushed me out of his way and as I was falling, I hit my head on the glass door. The glass broke and I received a large and deep laceration across the back of me head.
Benefit Application/Medical Release I am applying for recognition of my claim under the Ohio Workers' Compensation Act for work-related injuries that I did not purposely inflict. I request payment for compensation and/or medical expenses as allowable. Direct payment(s) to the providers of any medical services are authorized. I understand that I am allowing any provider who attends to, treats or examines me to release all medical, psychological, and/or psychiatric information that is related causally or historically to physical or mental injuries relevant to issues necessary to the administration of my workers' compensation claim to the Ohio Bureau of Workers' Compensation, the Industrial Commission of Ohio, the employer listed in this claim, that employer's managed care organization, and any authorized representatives. I further authorize the Ohio Rehabilitation Services Commission to release information about my physical, mental, vocational and social conditions that is related causally and historically to physical or mental injuries relevant to issues necessary for the administration of my workers' compensation claim to the aforementioned parties.
Injured worker signature
Date
Telephone number (419-555-1212 ) Fax number 419-824-1445 ( ) State

OH
Work number
12/09/2012
Health care provider name
Dr. Bunsen Honeydew, Flower Hospital
419-874-6608 ( )
Initial treatment date
12/09/20125
Street address
5200 Harroun Road
Telephone number 419-824-1444 ( ) City

Sylvania
9-digit ZIP code

43560
Treatment Info.
Diagnosis(es): Include ICD code(s)
2012 ICD-9-CM Diagnosis Code 873.0 Open wound of scalp, without mention of complication
Will the incident cause the injured worker to miss eight or more days of work? Health care provider signature
YES
NO
Is the injury causally related to the industrial incident? 11-digit BWC provider number
12345678910
YES Date
12/09/2012
NO
Employer policy number Telephone number (419-874-6608 )
BB635603050
Fax number 419-874-6609 ( )
s
CHECK IF E-mail address YES NO
Employer is self-insuring Injured worker is Owner/Partner/Member of Firm Manual number Federal ID number
58-12345678
6574354684
Employer Info.
Was employee treated in an emergency room?
Was employee hospitalized overnight as an in-patient?
YES
NO
If treatment was given away from worksite, provide the facility name, street address, city, state, ZIP code
s
CERTIFICATION - The employer certifies that the facts in this application are correct and valid.
REJECTION - The employer rejects the validity of this claim for the following reason(s) below:
FOR SELF-INSURING EMPLOYERS ONLY CLARIFICATION - The employer clarifies and allows the claim for the condition(s) below:
Employer signature and title

Jennifer Dieckhoff, General Manager
Date
12/09/2012
OSHA case number

670266625
BWC-1101 (Rev. 7/23/2002)
This form meets OSHA 301 requirements
FROI-1 (Combines C-1, C-2, C-3, C-6, C-50, OD-1, OD-1-22)

Workers Comp

Uploaded by

Copyright:

Available Formats

Workers Comp

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Workers Comp

Uploaded by

Copyright:

Available Formats

Claim Number:

Better Workers Compensation

Built with you in mind.

First Report of an Injury, Occupational Disease or Death

Last name, first name, middle initial

Home mailing address

9-digit ZIP code

s Female Male Country if different from USA

Injured Worker and Injury/Disease/Death Info.

Regular work hours 9 am To Fri Sat From Occupation or job title

Time employee 9:00 began work

State where hired

Date last worked AM s PM 12/09/2012 Date employer notified

Date returned to work

Injured worker signature

Telephone number (419-555-1212 ) Fax number 419-824-1445 ( ) State

Telephone number 419-824-1444 ( ) City

9-digit ZIP code

Diagnosis(es): Include ICD code(s)

Employer policy number Telephone number (419-874-6608 )

CHECK IF E-mail address YES NO

Was employee treated in an emergency room?

Was employee hospitalized overnight as an in-patient?

Employer signature and title

OSHA case number

BWC-1101 (Rev. 7/23/2002)

This form meets OSHA 301 requirements

FROI-1 (Combines C-1, C-2, C-3, C-6, C-50, OD-1, OD-1-22)

You might also like