First Report of Injury (FROI)

Who is responsible for completing the form?

• The employer is responsible for completing this form.
• If the employer is unable or refuses to file this form, the insurer is responsible for completing the form 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 form to begin the claim process. The department uses the information supplied on the form to review for compliance with the statutes and rules, and for statistical data.

What, specifically, is this form used for?

• To provide the insurer with the basic information necessary to start their claim process
• To comply with workers' compensation statutes and rules:
  • Minnesota Statutes 176.231, Subd. 1, 2 and 10 (timelines for reporting
  • Minnesota Statutes 176.231, Subd. 11 (substitute filing)
  • Minnesota Rules 5220.2530 (required information)
  • Minnesota Rules 5220.22820 (penalties)
• To comply with OSHA standards

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.
• This form must be 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;
  • the employer (copy);
  • the employee (copy) -- Note:  Always attach a Minnesota Workers' Compensation System
    Employee Information Sheet.
• 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 send this form to:
  • the Minnesota Department of Labor and Industry, Safety and Workers' Compensation Division
  • the insurer (copy)

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.firstgov.gov and click on "Employer ID Number" under "Business."	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.

Links

• First Report of Injury form
  
  
• Back to forms page