FROI Form | NJSIG - Keeping Dollars in the Classroom

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? Yes No

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? Yes No

Head Injury Details

Please check any symptoms that apply:

Loss of Consciousness

Nausea and/or Vomiting

Abrasion and/or Laceration

Significant Headache

Changes in Vision (Blurred and/or Double Vision)

Confusion and/or Memory Loss

History of Concussions

Currently Treating for Complications Related to Head Trauma/Concussion

If you've experienced two or more of these symptoms, please complete this form and head to the nearest Emergency Room for a concussion evaluation.

Injury Date

Injury Time

Person Reporting Claim

Person Reporting Phone Number Phone number of the person reporting the claim. Format: 609-386-6060

Person Reporting Email A confirmation email will be sent to this address.

Employee Information

Claimant SSN Format: 000-00-0000

Date of Birth

Age

Legal Name on Drivers License Or other state issued ID.

Marital Status

Gender

Address 0/5000

Home Phone Format: 609-386-6060

Cell Phone Format: 609-386-6060

Days Worked Number of days worked per week

Employment Status

Start of Work Day The time a typical work day starts.

End of Work Day The time a typical work day ends.

10 or 12 Month Employee 10 Month 12 Month

Wage Rate (Monthly)

Title

Personal Email

Employer Information

School District/Employer The name of district, not individual school.

Phone Number Format: 609-386-6060

Location of Accident

Contact

Location of Accident Off Premises

Location Address 0/5000

City

State

ZIP Code Format 00000.

Incident Information

Date Employer Notified

Injury Reported To

Injury Reported By

Supervisor Name

Witness Name

Witness Phone Number Format: 609-386-6060

Nature of Injury 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

Part of Body Affected 0/5000

Object Causing Injury 0/5000

How Injury Occurred 0/5000

Dominant Hand

Prior Medical Conditions Any medical condition the claimant admits to having prior to the date of the incident. 0/5000

Previous Workers' Comp Injury Provide dates/injuries. How did the injury occur and what body parts were injured? 0/5000

Primary Care Physician

Mitchell Card Received Yes No

Qual Lynx Received Yes No

Child Involved Yes No

Special Needs Child Yes No

Age

Additional Comments 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

FROI: First Accident Report

Employee Information

Employer Information

Incident Information