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Effective July 1, 2010
Purdue University will begin using JWF Specialty Company for the management of Worker’s Compensation claims. This change is being made in order to provide a decrease in cost to the University and an increase in personalized service to our injured employees.
Injuries on or after July 1, 2010 will be managed by JWF and require a new First Report of Injury (FROI) form be used. You will be able to submit the new FROI form online. Use the following links for the new FROI form or instructions:
Injuries before July 1, 2010 will continue to be handled by Liberty Mutual. If you have a current claim with Liberty Mutual, you will continue to deal with Liberty Mutual. Your claim will not switch to JWF.
Instructions for Completing
the
New First Report of Injury Form
(Effective July 1, 2010)
The form must be completed by the
employee’s direct supervisor or their designee.
For more detailed instructions than those below, view the tutorial
"How to Complete and Submit the First Report of Injury (FROI) Form".
- Download and complete the new "First Report of Injury" form located at the following URL (You must have Adobe Acrobat Reader 8 or above installed for this form to work correctly):
- If a yellow or purple bar does not appear atop the document window click the top graphic in the toolbar on the left edge of the window.
- If a yellow bar indicating JavaScript is disabled appears atop document window click the "Options" button and select "Enable JavaScript for this document always".
- Information in fields outlined in red MUST be entered before the form can be submitted. If fields are not highlighted click the "Highlight Fields" button on the purple bar near to top of the Adobe Acrobat window.
- Hovering your mouse pointer over the yellow encircled question mark ("?") near a field will open a popup window containing information to help you enter accurate information into that field.
- Print the completed form by clicking on one of the “Print Form” buttons and file a copy with the departmental records, separate from employee’s records.
- After printing the completed form, click one of the “Submit by Email” buttons to email it to the required recipients. If the Adobe Acrobat “Select Email Client” popup window appears asking if you want to use a desktop or internet email application use one of the following procedures:
- Pick the “Desktop Email Application” radio button if you are using an email application such as “Microsoft Outlook”, “Microsoft Outlook Express”, “Eudora”, or “Mail.”
- The addressee box will automatically populate with required recipients.
- Manually add your department’s business office contact and additional recipients as necessary.
- Pick the “Internet Email” radio button if if you are using an Internet email service like “Yahoo” or “Microsoft Hotmail.” If you choose this method you will have to save the completed form and email it manually to the following recipients:
- Christie.Nygaard@oldnationalins.com
- froi@purdue.edu
- tammy@purdue.edu
- dpopa@purdue.edu
- Your department’s business office contact and additional recipients as necessary.
- If unable to submit the form electronically use one of the alternative methods listed at the bottom of the form.
- Buttons linked to additional resources on the internet are located near the bottom of the FROI (If the Adobe Acrobat “Security Warning” popup window appears click the “Allow” button to continue on to the respective document or web page.).
- “Supervisor’s Accident Investigation Form”
- “Worker’s compensation and Disability Guide”
- “Worker’s Compensation Procedures”
- “Worker’s Compensation Witness Report Form”
- For more detailed instructions view the PowerPoint tutorial "How to Complete and Submit the First Report of Injury (FROI) Form".
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