It is essential that you report the incident as soon as possible and within 24 hours.  Do not make the assumption that the injured worker has notified us.  You can download the form here. After you fill it out, please fax it to us at 1-877-772-5246 right away.  You can call us if you need assistance at (513) 671-6300 or toll free 1-800-835-2577. Our intake specialists will be more than happy to assist you.

If you are an Employer:

The following information will be needed to file a first report of injury:

• Injured Worker Name
• Injured Worker SSN
• Injured Worker Mailing Address
• Injured Worker Home or Work Phone Number
• Date of Birth
• Date of Injury/Disease
• Gender
• Occupation or Job Title

• Gender
• Occupation or Job Title
• Description of Accident
• Type of Injury/Disease and Part(s) of Body Affected
• Employer Policy Number 
• Place of Accident or Exposure on Employer’s Premises
• Date Hired
• Date Employer Notified

If you are the injured worker:

The following information is required to file a claim:

• Injured Worker Name
• Injured Worker SSN
• Injured Worker Mailing Address
• Injured Worker Home or Work Phone Number
• Date of Birth
• Date of Injury/Disease

• Gender
• Occupation or Job Title
• Description of Accident
• Type of Injury/Disease and Part(s) of Body Affected
• Employer Policy Number