Important Information for NYSIF eFROI®

Once this electronic report is filed, it cannot be edited or resubmitted electronically.

If you have any questions about filing this report, please contact your NYSIF business office for assistance.

In order to successfully complete an Employer’s First Report of Injury via NYSIF eFROI®, you will need to have the following information. All fields marked with an asterisk (*) are required.

Policyholder Information:

Active policy number *

Mailing address and contact information *

E-mail Address *

Nature of Business *

Injured Worker/Employee/Claimant Information:

Name and Social Security Number *

Personal information, such as date of birth and gender *

Contact information, such as mailing address * and telephone number

Did employee give notice of accident/illness, If so, to whom? *

Injured employee’s supervisor’s name

Employment information:

Date of hire

Wage information – The injured employee’s gross average weekly wage *

Job title *

Employee’s usual days worked *

Time employee starts work

Date stopped working (the last day the injured employee was at work and ceased work activities because of this injury/illness)

Last day paid (The last calendar day the employee earned wages.)

How long employer will pay the employee? (Will the employer pay the employee for any lost time due to the injury/illness?)

Return-to-work information, date and rate employee returned to work

Accident/Illness and Injury Information:

Date of the accident/illness or injury *

What was employee doing at the time of injury? *

How did the accident occur? *

Where did the accident/illness happen? *

Nature of the injury, such as laceration or fracture *

Body part(s) injured *

Cause of injury *

Any witnesses? If so, who?

Names, addresses, contact information for medical providers and/or hospitals from whom the injured worker received treatment

If employee received medical care, on what date? *

If accident involves the employer’s motor vehicle, all automobile insurance information is required