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Workers' compensation -- Forms



First Report of Injury (FROI)

Who is responsible for completing this form?

  • The employer is responsible for completing the FROI.

  • If the employer is unable or refuses to file this form, the insurer is responsible for electronically submitting the completed FROI upon request from the department.

Why is this form needed?

  • The purpose of this form is to notify the insurer and the Department of Labor and Industry of a work-related injury or death. The insurer uses the FROI to begin the claim process. The department uses the information supplied via the FROI to review for compliance with the statutes and rules, and for statistical data.

What, specifically, is this form used for?

When is this form completed?

  • This form should be completed and filed by the employer whenever anyone believes a work-related injury or illness has occurred, and must be filed:

    • within 10 days of the first day of disability or the date they were aware of the disability, whichever is later; and

    • within 48 hours of a death or serious injury -- the employer must report the occurrence to the department, followed by the filing of the completed form within seven days of the occurrence.

  • The FROI must be electronically filed with the Minnesota Department of Labor and Industry by the insurer if the claim results in the employee's inability to work for a period of more than three days (or results in permanent partial disability):

    • within 14 days of the first day of disability or the date the employer was aware of the disability, whichever is later;

    • within 10 days of a request from the department, to complete a substitute filing of this form if the employer is unable or refuses to file this form.

Where is this form sent?

  • The employer must:

    • send this form to the workers' compensation insurance company;

    • send a copy of this form to the employee -- Note:  Always attach a Minnesota Workers' Compensation System Employee Information Sheet; and

    • retain a copy of the FROI for its records.

  • Death or serious injury must be reported to the department by telephone at (651) 284-5041, by fax at
    (651) 284-5731, by telegraph addressed to the department or by a personal visit to the department.

  • The insurer must:

    • file the FROI electronically with the Minnesota Department of Labor and Industry, Workers' Compensation Division, via electronic data interchange (EDI) or the eFROI Web portal (see www.dli.mn.gov/Edi.asp for additional information about electronic filing); and

    • retain a copy of the FROI for its records.


Frequently asked questions

Employer questions
Box 39 Description Where obtained Why needed
Employer FEIN Employer federal employment identification number (FEIN)

A nine-digit code used to
identify a business entity; also
known as the federal tax identification number.
Check first with the employer's accounting or human resources department, whichever handles tax reporting to the Internal Revenue Service.

For more information about this number, visit www.usa.gov/Business/Business-Gateway.shtml and click on "Get an Employer ID Number."

This number is used by the Department of Labor and Industry to uniquely identify employers.
Box 40 Description Where obtained Why needed
Unemployment ID# Unemployment identification number

A 10-digit number assigned by the Department of Employment and Economic Development to the employer shown on the
First Report of Injury
form.
Check first with the employer's accounting or human resources department, whichever makes quarterly unemployment insurance payments.

Then, if necessary, check with the Department of Employment and
Economic Development at
(651) 296-6141.

This number is used by the Department of Labor and Industry to uniquely identify employers.


Insurer questions
Box 44 Description Where obtained Why needed
NAICS code North American industry classification system
(NAICS) code

This six-digit code indicates
the type of business on the
First Report of Injury
form.
NAICS codes are assigned by
the Department of Employment and Economic Development. Call
(651) 296-6141 and follow prompts to employer
customer service.
This code makes it
possible to compare
workers' compensation
data by industry and to identify high-risk industries.
Box 48 Description Where obtained Why needed
Policy # or self-insured
certificate #
The employer's workers' compensation policy
number or, if the employer
is licensed to self-insure,
the certificate number.
The policy number should be listed on the actual policy
issued by the insurer. For
self-insured employers, the certificate number is
assigned by the Department of Commerce.
These numbers help identify the employer and insurer, and verify that the proper legal coverage is in force.


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