First Report of Injury, Occupational Disease or Death
To report an injury, complete the following form and click submit.  Please fill in as much of this form as possible to allow us to process quickly.

* Indicates a required field.

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.29 13.48).  

This form is being completed by: *  
Name of person reporting injury: *
Title of person reporting injury:
What is your email address?
What is your phone number? - - ext
Injured Worker Information
Last Name: * First Name: *
Address: * City: *
State: * Zip:
Home Phone: Work Phone:
SSN: Date of Birth:
Department: Job Title:
Work Week: Number of Dependents:
Work Hours:  
Sex: Marital Status:
Employer Information
Employer Name: Address:
City: State:
Zip: Phone:
Policy Number: *
Injury Information
Date of Injury: * Time of Injury:
  Did Accident Occur on Employer Premises?    
Accident Location: Accident Type:
Date Last Worked: Return to Work Date:
Nature: Body Part/Location:
 Accident Description:
 Was outside medical treatment sought?  


Treatment Information
Provider: Address:
City: State:
Zip: Phone:
Initial Treatment Date: