Report a Claim
In order to submit your claim electronically, please follow the instructions below.
1. Select the State in which the injury occurred by clicking on the map or drop-down.
2. Enter information directly into the First Report Of Injury (FROI) form.
3. Once you’ve completed the information save the document, either by clicking the Save icon or selecting File on the menu and Save As to name the file as you wish.
4. Submit the completed FROI via email to firstname.lastname@example.org or via fax to (321) 206-4525.