Follow the steps to fill out the Efroi form online.

1. Press the ‘Get Form’ button to access the Efroi document and open it in your preferred online editing platform.
2. Begin filling in the policyholder information at the top of the form. Enter the policyholder's name, policy number, industry type code, phone number, and mailing address including city, state, and ZIP code.
3. Next, provide the claimant information. Fill in the claimant's name, address, city, state, phone number, gender, ZIP code, social security number (SSN), date of birth, and job title.
4. Indicate whether the employee gave notice of the accident or illness. If so, specify to whom the notice was given, typically their supervisor.
5. Enter the employment information. Fill in the date of hire, claimant's gross average weekly wage, usual days worked, time the claimant started work on the date of the incident, and the date they stopped working due to the injury.
6. Complete the details regarding the last day paid, whether the employer is continuing payments, and if the claimant has returned to work, including the return date and any restrictions.
7. Document the accident or illness information. Enter the date of the accident, what the employee was doing at the time, how the accident occurred, and the specific location of the incident.
8. Note whether the injury is related to a work-related injury previously and if any witnesses were present during the incident.
9. If applicable, include medical provider information detailing whether the employee received medical care, including the provider’s name, address, and contact information.
10. Once all fields are completed, review the information for accuracy. Save your changes, and you can also opt to download, print, or share the form if necessary.

Complete your documents online to ensure efficient processing of your claim.