FROI | Montana University System

Hover above to get more description of what information is to be provided in the space. Employee Information

First Name

Last Name

Middle Name or Initial

Date of Birth

Social Security Number (SSN)

Phone Number

Gender

Address

City

State

Zip

Position

Job Title

Department

Work Location

Work Phone Number

Report Prepared By

Employment Status

Number of Days Worked (per week)

Supervisor

Supervisor's First Name

Supervisor's Last Name

Supervisor's Email

Supervisor's Phone Number (cell preferred if remote)

Accident Information

Date of Injury

Time of Injury

Did condition develop over more than 1 work shift?

Yes

Cause of Injury

Part of Body

Nature of Injury

Accident Description

Accident Address or Location

Medical Treatment

If you seek medical attention, submit the Employer’s Copy of the Medical Status Form, completed and signed by the medical provider, to your supervisor immediately following your appointment.

Type of Medical Treatment

No treatment at this time

Plan to seek treatment at...

Received treatment at...

If you later decide to seek medical attention, please notify your Claim Coordinator.

If you receive a Prescription: Refer to the important “Rx first-fill information” in the confirmation emailed to you immediately after you submitted the FROI, or call your campus claim coordinator.

Where did you / will you receive treatment?

Medical Provider

Medical Provider's Name

Provider's Phone Number

Provider Address

City

State

Zip

Hospital

Hospital Name

Hospital Phone Number

Hospital Address

City

State

Zip

Communications / Work Status

Date Employer/Supervisor Notified

Accident Reported To

Witnesses

Worked Next Scheduled Shift

Dates of Missed Work (if any)

Confirmation

Please select your method of signature:

E-signature

E-signature may only be provided by individual making claim (injured employee); not by a supervisor or assistant. The print, sign and mail option must be used if employee making claim is unavailable to personally E-sign.

Print, sign and mail

Anyone other than employee MUST select PRINT, SIGN, MAIL if you are assisting with the FROI. Do not select Esign. The employee's valid wet-signature can be secured later if they are not available to sign.

Electronic Signature

Please read Montana's medical release language below prior to signing the FROI. An Employee making claim may elect to provide an electronic signature (E-signature) or elect to print and sign a hardcopy of the FROI. If the employee is not available to personally provide their E-signature, anyone assisting with the FROI, must select the Print, sign, mail option. Continue completing and submitting the electronic FROI without signature to avoid unnecessary delay - the employee's wet-signature, attesting to the release of medical information, can be secured separately.

"This is my claim for workers' compensation benefits due to the on-the-job injury, occupational disease, or death of the below-named worker. I understand that signing this claim for compensation authorizes the release to the workers' compensation insurer (and its agents) and the Montana Uninsured Employers' Fund of Social Security records, rehabilitation records and all health care information (medical records, pursuant to HIPAA, Public Law 104-191, 42 USC section 1301, et. seq., and section 39-71-604, MCA) that are directly relevant to this claimed injury, disease or death. I also understand that if I obtain or exert unauthorized control over workers' compensation benefits to which I am not entitled, I may be prosecuted for theft."

I, the injured worker or beneficiary, acknowledge that by the dual action of checking the box and entering my name as provided below, I am providing my electronic signature.

I certify as written above

Signature of worker filing claim, or their beneficiary:

Print, Sign and Mail

"This is my claim for workers' compensation benefits due to the on-the-job injury, occupational disease, or death of the below-named worker. I understand that signing this claim for compensation authorizes the release to the workers' compensation insurer (and its agents) and the Montana Uninsured Employers' Fund of:, Social Security records; rehabilitation records; and all health care information (medical records, pursuant to HIPAA, Public Law 104-191, 42 USC section 1301, et. seq., and section 39-71-604, MCA) that are directly relevant to this claimed injury, disease or death. I also understand that if I obtain or exert unauthorized control over workers' compensation benefits to which I am not entitled, I may be prosecuted for theft."

After submitting your report, the FROI will be sent to your supervisor for completion, printing and signature. Contact your supervisor immediately to finalize the FROI with both of your signatures and delivery to the campus claim coordinator.

Signature

Print Name

Date

First Report of Injury (FROI) Employee Report

Great Falls College MSU

Electronic Signature

Print, Sign and Mail

SUPERVISOR, please click the button below to proceed to the SUPERVISOR portion of the claim form.