Filling out the Accident Report

Report of Industrial Injury or Occupational Disease

To speed up the claim process, make sure the accident report is:

greencheckmark Understood by the worker.

  • If your patient prefers to communicate in a language other than English, you can get an interpreter. Find out how.
  • Note: For Spanish-language instructions on how to fill out the ROA, you can order copies and L&I will mail them to you. For the following languages, downloadable instructions will soon be available. You can print them and give them to the worker.
    Expand/collapse Additional languages
  • Amharic
  • Arabic
  • Bosnian
  • Burmese
  • Cambodian
  • Chinese Traditional
  • Chinese Simplified
  • Farsi
  • Korean
  • Laotian
  • Punjabi
  • Russian
  • Somali
  • Spanish
  • Tagalog
  • Vietnamese

greencheckmark Filled out completely, leaving areas blank may delay processing of the claim and your bills. If the condition is a disease, enter "N/A" for "not applicable" in both of the following boxes:

  • Date of injury.
  • Time of injury.

greencheckmark As specific as possible.

  • Include a complete diagnosis and appropriate Common Diagnostic Codes (ICD-9 codes). Clarify a specific body site and the definition of the injury.
  • If your patient is unable to perform any work due to the injury or disease, estimate how much time the injured worker will lose due to the injury.

greencheckmark Signed by both you and your patient.

greencheckmark Submitted promptly with copies of the:

  • History and physical,
  • Emergency room evaluation, or
  • Your office notes.

Consider contacting the employer

  • If you have questions or concerns about the relationship between an exposure and the illness being treated.
  • To request material safety data sheets (MSDS).
  • To walk through the job site.

See Billing L&I for information on reimbursement.

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