NYSIF - Review report of Injury

eFROI

PolicyHolder Info
Employee Info
Accident Info
Injury Cause
Medical
Work Info
Submit

All fields marked with an asterisk(*)are required.
If you have any technical questions or issues, please contact the NYSIF Help Desk at 1-877-435-7743 for further assistance. Monday through Friday from 8:00 AM to 6:00 PM.

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

Yes
No

* Are you Resuming an eFROI?

Yes
No

*Loss ID

*NYSIF Policy Number

(for example: enter A123-4567-8 as 12345678)

* Is injured worker a Volunteer?

Yes
No

Retreiving Barging Unit List... Please Wait

*Bargaining Unit

*Policy Entity

(mm/dd/yyyy)

*Date of injury/illness

(mm/dd/yyyy)

* Does Injured Worker have a SSN ?

Yes
No

Required when "Have a SSN" is yes.

*Injured Employee’s Social Security Number

* Does Injured Worker have a NYS Employee ID or ‘N-number’?

Yes
No

*NYS Empl ID

*First Name

M. I.

*Last Name

(mm/dd/yyyy)

*Date of Birth

(mm/dd/yyyy)

Employee Address

*Address Line 1

Address Line 2

Apt.

*Country

*Zip Code

*City

State

*Province

*Postal Code

Preparer Info

* First Report of Injury Preparer Type

Employer
Third Party
NYSIF Employee

If "Employer" selected, provide preparer information:

*First Name

*Last Name

*Title

*Telephone Number

(with area code)

Phone Extension

(Up to 5 digits)

If "NYSIF Employee" selected, provide NYSIF Employee preparer information:

*First Name

*Last Name

*Title

*Telephone Number

(with area code)

Phone Extension

(Up to 5 digits)

*eFROI Initiator e-mail

(This email address may be an individual or group email distribution.)

Broker/Saftey Group e-mail

(This email address will receive the same emails as the eFROI Initiator)

If "Third Party" selected, provide Third Party preparer information:

*First Name

*Last Name

*Title

*Telephone Number

(with area code)

Phone Extension

(Up to 5 digits)

*Company Name

*Address Line 1

Address Line 2

Suite

*Country

*Zip Code

*City

State

*Province

*Postal Code

OSHA Case Number

*eFROI Transaction ID

(for example Transaction ID: begins with NP or SP followed by numbers and ending with Alphabets)

Verifying policy please wait...

If you have any technical questions or issues, please contact the NYSIF Help Desk at for further assistance. Monday through Friday from 8:00 AM to 6:00 PM.