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- A mandatory field means that the First Report will be returned to the employer/insurer for completion. A claim will not be started in the WCB system.
A required box means that a claim will be started in the WCB system and missing information will be requested from the insurance carrier via the Reconciliation Report.
- All other boxes should be completed if information is known.
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1. WCB File Number - Mandatory when filing a Corrected Prior Report (box 7a check yes)
In the Reason for Report section, it is mandatory that at least one box from 2(a) through 7(a) be checked-marked. If FROI is not a lost time, lost earnings, Med only, or corrected report then Report Only (character position 1698) must be yes.
2(a). Reason Lost Time - If 2(a) is yes, then 2(b) is required.
5. Death - If 5 is check-marked, then Date of
Death is required.
8. UIAN - Required
9. FEIN - Required
10. Employer Name - Mandatory
11. Employer Mailing Address - Required
12. Employer Mailing City - Required
13. Employer Mailing State - Required
14. Employer Mailing Zip - Required
17. Employer Physical Location - Required if physical
location is different from mailing address
18. Injury Location - Required give location if injury
did not occur on employer's premises
Insurer, TPA, Self-administered (one must checked) - Required
If Insurer or TPA box is check-marked, then boxes 19, 22, 23, 24, and 25 are Required.
If Self-administered Employer box is check-marked boxes 19 - 26 are optional.
27. Employee Last Name - Mandatory
28. Employee First Name - Mandatory
31. Employee SSN - Required
32. Employee Gender - Required
33. Employee Address - Required
34. Employee City - Required
35. Employee State - Required
36. Employee ZIP - Required
37. Employee Date of Birth - Required
41. Employee Work for Another Employer - Required
42. Date of Injury - Mandatory
43. Incapacity Date - Mandatory if boxes 2(a) is check-marked.
44. Time EE Began Work - Required
45. Date ER Notified Insurer - Required if Insurer or
TPA box check-marked. Not required if Self-administered box is checked
46. Time of Injury - Required
47. Return to Work Date - Required if 2(a) is checked.
If box 47 is yes, must provide a date.
48. Specific Injury - Required
49. Body Part Affected - Required
52. Injury Events - Required
58. Preparer - Required
All Claim Administer Information - Required (if applicable)