Welcome to SAIF Corporation's Forms Library

Form Name	Ref. No.	Option
ACORD™ workers' compensation application form Use this form to apply for SAIF coverage. Please contact us for assistance.	ACORD	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	n/a
CMS-1500 form For medical providers, to ensure proper processing of billings. Also see "How to expedite payment".	CMS-1500	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-3327	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.	F-3231	F-3231s Spanish
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.	LS-202	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.	English Spanish Russian Vietnamese	Word - English Word - Spanish Word - Russian Word - Vietnamese
Personal Coverage Application for LLC Members To elect coverage for an LLC member, this form is to be completed by an LLC member.	X-1462	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 or Nonsubject Partners To elect coverage for a sole proprietor or nonsubject partner, this form is to be completed by the owner or a partner in the business.	X-1461	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	n/a
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.	F-3135	n/a
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 fax it to SAIF at 800.475.7785 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.	F-3056	F-3056s Spanish
Return-to-Work Job Description form  - Regular This job description form is to be completed by the employer and submitted to the worker's physician for approval.	RTW	Word.doc
Return-to-Work Job Description form - Modified This job description form is to be completed by the employer and submitted to the worker's physician for approval.	RTW	Word.doc
Return-to-Work release form This DCBS release form is to be completed by the injured worker's physician. (440-3245)	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.	RTW	Word.doc
UB form For Medical providers, to ensure proper processing of billings. Also see "How to expedite payment."	UB-92	n/a
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	F-3312	Word.doc
Wellpartner Mail Order Pharmacy form Use this form to have your regular, ongoing prescriptions delivered to your home for no extra charge.	p-08-08	n/a
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

Upon completion, unless otherwise noted, forms can be submitted to SAIF Corporation as follows:

• Mail completed forms to: SAIF Corporation, 400 High St SE, Salem, OR 97312
• Or FAX to these numbers:
  - Acord™ form: 503.373.8769
  - EAIP forms: 503.945.3652
  - Forms 801 & 827 forms: 800.475.7785
  - Nondisabling Claims Reimbursement: 503.373.8400

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