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Welcome to SAIF's forms library

Need to file a claim? You can download or electronically file the 801 form, or order printed forms. (Electronic filing is only available to SAIF customers who use Business Online.)

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Form File format
Accident/Incident Analysis: ACTION form (S-924)
This provides a step-by-step approach to accident analysis. Learn more about accident analysis 

English | PDF 

Accident/Incident Analysis: Incident Report form (S-767)
Immediate supervisor should complete this form promptly with worker after an incident or injury occurs. Learn more about accident analysis 

English | PDF | Word

Spanish | PDF 

ACORD™ workers' compensation application form
Use this form to apply for SAIF coverage. Please contact us for assistance. Learn more about obtaining coverge

English | PDF

ACORD (form fields)

Attending Physician form (827) 
This form is to be completed by treating physicians only. Provide completed copies of third and fourth pages to injured worker. Learn more about reporting a workplace injury

English | PDF | Word

Spanish | PDF | Word

Business Change form (G-968)
Use to notify SAIF of changes in ownership, address, business name, business description, or canceling coverage.
English | PDF
Cancellation of Election for Coverage as a Worker (X-3000)
To cancel personal election coverage for an owner, this form is to be completed by an authorized representative of the business.
English | PDF
Designation of Corporate Officer Exemption form | Construction, Timber Harvest, or Landscape Industries (X-3267)
To exempt a corporate officer from coverage, this form is to be completed by an authorized corporate representative. Learn more about corporate officers

English | PDF

Designation of Partner or LLC Member Exemption form | Construction or Landscape Industries (X-3327b)
To exempt a partner or LLC member from coverage, this form is to be completed by a partner or LLC member. Learn more about partnerships | Learn about LLCs
English | PDF
Education/Work History form (F-3231)
Information regarding an injured worker's work history is required by the WCD to rate the level of disability and to determine eligibility for vocational assistance benefits.

English | PDF

Spanish | PDF

EFT form (Authorization Agreement for Electronic Payments)
Have your payments directly deposited into your bank account or applied to a VISA-branded debit card. Learn more about electronic payments

English | PDF

Spanish | PDF

ERM-14 form | Confidential Request for Ownership Information
Use this NCCI form to notify SAIF of ownership and/or entity changes in your business.   
English | PDF
Federal Longshore form (LS-202)
To file federal longshore claims, use form LS-202. The form is only for use by employers who have a federal endorsement. Send it directly to the U.S. Department of Labor, Longshore & Harbor Workers', 1111 Third Ave., Suite 620, Seattle WA 98101, within 10 days of the injury and copy SAIF. Learn more about federal coverage
English | PDF
Job offer letter
This sample letter is provided by SAIF as a service to its policyholders for use in a return-to-work program. Learn more about return-to-work programs

English | PDF |Word
Spanish | PDF | Word

Russian | PDF | Word 
Vietnamese | PDF | Word 

Nondisabling Claims Reimbursement form (F-3135)
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. Learn more about nondisabling claims reimbursement
English | PDF
Notice of Agent Cancellation (G-1050)
Have you retired, sold your agency, or are no longer licensed? Complete our Notice of Cancellation form. Once completed, it can be emailed, faxed or mailed to SAIF.

 
English | PDF

Oregon OSHA forms 300 and 300A log (3353)
Used for recording work-related injuries and illnesses; learn more about Oregon OSHA 
English | PDF
Personal coverage application for nonsubject corporate officers (X-1460)
To elect coverage for a nonsubject corporate office, this form is to be completed by an authorized corporate representative. Learn more about corporate officers
English | PDF
Personal coverage application for sole proprietors, nonsubject partners, or nonsubject limited liability company (LLC) members (X-1461b)
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. Learn more about sole proprietorships | Learn more about partnerships | Learn more about LLCs
English | PDF
Policyholder's Cancellation of Workers' Compensation Insurance (X-773)
To cancel your workers' compensation insurance policy, this form is to be completed by an authorized representative of the business.
English | PDF
Premium credit application (X-948)
This application is for policyholders or agents to complete.
English | PDF | Word
Purchase Justification Request form (F-3311)
This EAIP form is for SAIF policyholders only. See Employer-at-Injury Program information and OAR 436-105. Learn more about EAIP
English | PDF
Report of Job Injury or Illness form 801
Customized specifically for SAIF customers. When you become aware of an on-the-job injury, complete the 801 form and submit it electronically (via Business Online), or print it and submit it by email, fax, or mail as soon as possible. Be sure to make copies for yourself and the worker. Learn more about reporting a workplace injury

If you are a SAIF policyholder and would like 801 forms sent to you, click here.

English | PDF |

PDF (form fields)

Spanish | PDF |

Spanish (form fields)

Request for Lost Earning form
Injured workers should submit this form to SAIF to request compensation for wages they lost to attend a medical exam that SAIF required. 

English | PDF 

Spanish | PDF

Request for Reimbursement of Expenses form (F3056) 
This request is for reimbursement to injured workers for mileage, medical prescriptions or lodging for their claim. Learn more about getting reimbursed

English| PDF

Spanish | PDF

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. Learn more about return-to-work programs

Regular | PDF | Word

Modified | PDF | Word

Return-to-Work release form (440-3245)
This DCBS release form is to be completed by the injured worker's physician. Learn more about return-to-work programs
English | PDF | Word
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. Learn more about return-to-work programs
English | PDF | Word
Verifiable time record
This file includes a sample of one type of daily verifiable time record, and a blank form. Learn more about VTR
English | PDF | Word
Wage Request form (G-1023)
If your employee is owed time-loss benefits, you will be asked to provide wage information. Learn more about injured worker benefits
English | PDF | Word
Wage Subsidy Request form (F-3312)
This EAIP wage subsidy reimbursement request form is for SAIF policyholders only. See OAR 436-105. Learn more about EAIP
English | PDF

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

  • Email 801 forms to saif801@saif.com
  • 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: 503.584.9805
    - Forms 801 and 827: 800.475.7785
    - Nondisabling Claims Reimbursement: 503.373.8400

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