Report EVERY workplace injury to your employer in writing, even if it seems minor

See a doctor as soon as possible — delays weaken your claim

Document everything: photos of the scene, witness names, your symptoms

Workers' Compensationmoderate

First Report of Injury (Generic FROI)

FROI · State Workers' Compensation Agencies

Report of workplace injury or occupational disease filed with the state agency and insurer. Required within 3-10 days of injury depending on state. Establishes the claim in the system.

Form Details

Total fields: 45
Auto-fillable: 28 (62%)
Time without BeneFill: 30 minutes
Time with BeneFill: 8 minutes
Time saved: 22 minutes
Filled by: patient
Frequency: per incident
State-specific: Yes — form may vary by state

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Where to Submit This Form

📬

Employer files with their workers' comp insurance carrier

The employer is responsible for filing — not the employee.

Filing Deadline

Employer must report within 3-10 days (varies by state). Employee should report the injury to employer IMMEDIATELY.

Processing Time

Insurance carrier has 14-30 days to accept or deny the claim (varies by state).

What Happens Next

The insurance carrier will assign a claims adjuster. You'll receive information about authorized medical providers.

Tips for This Form

✓ Report EVERY workplace injury to your employer in writing, even if it seems minor
✓ See a doctor as soon as possible — delays weaken your claim
✓ Document everything: photos of the scene, witness names, your symptoms
✓ You have the right to choose your own doctor in most states (check your state's rules)

You Might Also Need

Workers' Comp Treatment Authorization Request

UR/PA (state/insurer specific) · Workers' Comp Insurers / UR Organizations

Request for approval of specific medical treatment, surgery, or diagnostic test related to a workplace injury. Insurer must respond within state-mandated timeframes.

California Workers' Comp Claim Form

DWC-1 · California Division of Workers' Compensation

Employee claim form for workers' compensation benefits in California. Employer must provide within one working day of learning of a workplace injury or illness.

New York Employee Claim

C-3 · New York Workers' Compensation Board

Employee's claim for compensation filed with the NY Workers' Compensation Board. Must be filed within 2 years of the accident or within 2 years of when the claimant knew or should have known the condition was work-related.

Texas Employee's Claim for Compensation

DWC-041 · Texas Department of Insurance, Division of Workers' Compensation

Employee's claim for compensation for a work-related injury or illness in Texas. Must be filed within one year of injury or within one year of when the employee knew or should have known the condition was work-related.

Florida First Report of Injury or Illness

DFS-F2 · Florida Division of Workers' Compensation

Florida's first report of injury or illness form. Employer must file within 7 days of knowledge of an injury or within 24 hours if the injury results in death.

North Carolina Notice of Accident to Employer

Form 18 · North Carolina Industrial Commission

Notice of Accident to Employer and Claim of Employee. Must be filed when injured on the job in North Carolina. Written notice to employer required within 30 days; claim filed within 2 years.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Workers' Compensation Agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.