| Form Name |
Ref. No. |
Option |
|
Accident/Incident Analysis
ACTION form
A step-by-step approach to accident analysis
Incident Report form
Immediate supervisor should complete this form promptly with worker after an incident or injury occurs.
|
S924
English
Spanish
|
Word (English)
|
ACORD™ workers' compensation application form
Use this form to apply for SAIF coverage. Please contact us for assistance. |
ACORD (form fields)
|
n/a |
Attending Physician form
This form is to be completed by treating physicians only. Provide completed copies of 3rd and 4th pages to injured worker. |
827 |
827 - Spanish
Word - English
Word - Spanish |
Business Change form
Use to notify SAIF of changes in ownership, address, business name, business description or canceling coverage. |
G-968 |
n/a |
Cancellation of Election for Coverage as a Worker
To cancel personal election coverage for an owner, this form is to be completed by an authorized representative of the business. |
X-3000 |
n/a |
Designation of Corporate Officer Exemption form – Construction, Timber Harvest or Landscape Industries
To exempt a corporate officer from coverage, this form is to be completed by an authorized corporate representative. |
X-3267
|
n/a |
Designation of Partner or LLC Member Exemption form – Construction or Landscape Industries
To exempt a partner or LLC member from coverage, this form is to be completed by a partner or LLC member. |
X-3327b |
n/a |
Education/Work History form
Information regarding your work history is required by the WCD to rate your level of disability and to determine your eligibility for vocational assistance benefits. |
|
Spanish |
ERM-14 form – Confidential Request for Ownership Information
Use this NCCI form to notify SAIF of ownership and/or entity changes in your business. |
ERM-14 |
n/a |
Federal Longshore form
To file Federal Longshore claims, use form LS-202. The LS-202 form is only for use by employers that have a federal endorsement. The LS-202 form needs to be filed directly to the US Department of Labor, Longshore & Harbor Workers', 1111 Third Ave., Suite 620, Seattle WA 98101 within 10 days of the injury and copied to SAIF. |
|
n/a |
Job Offer Letter
This sample letter is provided by SAIF as a service to its insureds for use in a return-to-work program. |
|
Word - English
Word - Spanish
Word - Russian
Word - Vietnamese
|
Nondisabling Claims Reimbursement form
The Nondisabling Claims Reimbursement program is available for new and renewing policyholders on an annual basis, or on the first day of the next calendar quarter for existing policies. If you choose to participate, return a signed form to SAIF. |
|
n/a |
OR-OSHA Forms 300 and 300A Log
Used for Recording Work-Related Injuries and Illnesses |
3353 |
n/a |
Personal Coverage Application for Nonsubject Corporate Officers
To elect coverage for a nonsubject corporate office, this form is to be completed by an authorized corporate representative. |
X-1460 |
n/a |
Personal Coverage Application for Sole Proprietors, Nonsubject Partners or Nonsubject Limited Liability Company (LLC) Members
To elect coverage for a sole proprietor, nonsubject partner, or nonsubject LLC member this form is to be completed by the owner, a partner or an LLC member in the business. |
|
n/a |
Policyholder's Cancellation of Workers' Compensation Insurance
To cancel your workers' compensation insurance policy, this form is to be completed by an authorized representative of the business. |
X-773 |
n/a |
Premium Credit Application
This application is for Policyholders or Agents to complete. |
|
X-948.doc |
Report of Job Injury or Illness form 801
Customized specifically for SAIF customers. When you become aware of an on-the-job injury, just complete the 801 form and email, fax, or mail it to us as soon as possible. Be sure to make photocopies for yourself and your injured worker.
If you are a SAIF policyholder and would like 801 forms sent to you, click here. |
801
801 (form fields)
|
801s Spanish
801s Spanish (form fields)
|
Request for Reimbursement of Expenses form
This request is for reimbursement to injured workers for mileage, medical prescriptions or lodging for their claim. |
|
Spanish |
Return-to-Work Job Description forms
This job description form is to be completed by the employer and submitted to the worker's physician for approval. |
Regular
Modified
|
Regular.doc
Modified.doc
|
Return-to-Work release form
This DCBS release form is to be completed by the injured worker's physician. (440-3245) |
|
Word.doc |
Return-to-Work Sample Policy form
This is a sample return-to-work policy that employers can use as a guideline when developing and/or updating their written return-to work policy and procedures. As with any policy, you should also contact your legal counsel before and during the implementation of your program. |
|
Word.doc |
Verifiable time record
This file includes a sample of one type of daily verifiable time record, and a blank form. |
VTR sample |
VTR Word.doc |
Wage Request form
If your employee is owed time loss benefits, you will be asked to provide wage information. Use this form to report the employee’s gross wages for the 52 weeks preceding the date of the injury. |
G-1023 |
Word.doc |
Employer-at-Injury Program (EAIP)
Wage Subsidy Request form
This EAIP wage subsidy reimbursement request form is for SAIF policyholders only. See OAR 436-110 and/or WCD Bulletin 260. Learn more about EAIP |
|
Word.doc |
Employer-at-Injury Program (EAIP)
Work-site Modification and Purchase Justification form
This EAIP form is for SAIF policyholders only. See Employer-at-Injury Program information and OAR 436-105/110. Learn more about EAIP |
F-3311 |
Word.doc |