eFROI

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Start or Resume Your eFROI

All fields are required unless otherwise stated.

Do you have an eFROI Transaction ID and/or a Loss ID?

Yes

No

NYSIF Policy Number For example: A123-4567 as 1234567.

Employee Address

Address Line 1

Address Line 2 (optional)

Apt (optional)

Country

Zip Code

+ 4 (optional)

City

State

Preparer Info

First Report of Injury Preparer Type

Employer

Third Party

NYSIF Employee

Provide Third Party Preparer Information:

First Name

Last Name

Job Title

Telephone Number Numbers only - include area code

Extension (optional) Up to 5 digits

Company Name

Address Line 1

Address Line 2 (optional)

Suite (optional)

Country

Zip Code

+ 4 (optional)

City

State

eFROI Initiator Email This email address may be an individual or group email distribution

Broker/Safety Group Email (optional) This email address will receive the same emails as the eFROI Initiator

OSHA Case Number (optional)