Workers' Compensation First Report of Injury (FROI)- Employee
Fill out this form to report first report of injury. The submission will route to Human Resources for review. For questions, please contact Toni Bahl at tbahl@orionassoc.net or 763-450-5003 or Andrea Hagen at ahagen@orionassoc.net or 763-450-5008.
Company
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Please Select
Orion Associates
Meridian Services
Zenith Services
Specifically list what parts of your body were involved and circle on the diagram.
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List the body parts injured (EX: right wrist)
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Describe the incident which resulted in the injury. EX: slipped and fell in the parking lot due to the snow
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I have received medical treatment
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Yes
No
I am unsure if I will seek medical treatment
Signatures
I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Employee Legal Name
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Legal First Name
Legal Last Name
Employee Email
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example@example.com
Employee Phone Number
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Please enter a valid phone number.
Employee Signature
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Date of Signature
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-
Month
-
Day
Year
Date
I have clicked "Preview PDF" and reviewed my form for accuracy
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Yes
No
Please verify that you are human
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Preview PDF
Submit
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