FROI: First Accident Report

If your injury requires immediate attention or is life threatening, please report to the nearest emergency room.

For prompt handling of your claim, please ensure all fields are completed to the best of your ability

Is Medical Treatment Being Requested?
If treatment is being requested, an NJSIG representative will reach out to you on the next business day.
Does your injury involve your head, face, or neck?
Phone number of the person reporting the claim. Format: 609-386-6060
A confirmation email will be sent to this address.

Employee Information

Format: 000-00-0000
Or other state issued ID.
Format: 609-386-6060
Format: 609-386-6060
Number of days worked per week
The time a typical work day starts.
The time a typical work day ends.
10 or 12 Month Employee

Employer Information

The name of district, not individual school.
Format: 609-386-6060
Format 00000.

Incident Information

Format: 609-386-6060
Nature of injury or illness names the principal physical characteristic of a disabling condition, such as sprain/strain, cut/laceration, or carpal tunnel syndrome. 0/5000
Any medical condition the claimant admits to having prior to the date of the incident. 0/5000
Provide dates/injuries. How did the injury occur and what body parts were injured? 0/5000
Mitchell Card Received
Qual Lynx Received
Child Involved
Special Needs Child
If initial treatment has been directed by a school nurse, please provide the name and address of the facility. If no treatment has been directed, please type "no treatment directed" into the box above. 0/10000