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Name Form Description File

801 | Report of Job Injury or Illness

801

Customized specifically for SAIF customers. When you become aware of an on-the-job injury, complete the 801 form and submit it electronically by logging into your online account, or print it and submit it by email, fax, or mail as soon as possible. Be sure to make copies for yourself and your 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 (fillable form)

Spanish | PDF

Spanish (fillable form)

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 

Spanish | PDF

ACORD™ workers' compensation application form

ACORD

Use this form to apply for SAIF coverage. Please contact us for assistance. Learn more about obtaining coverage

ACORD (fillable forms)

Agency profile

M0130

Questionnaire for potential appointed agencies

PDF (fillable form)

Agent Cancellation Notice

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

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 | Word

Spanish | 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)

X-4004

Have your payments directly deposited into your bank account or applied to a VISA-branded debit card. Learn more about electronic payments.

English | PDF

Employer-at-Injury Program (EAIP) 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

Spanish | PDF

Employer-at-Injury Program (EAIP) 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

Spanish | PDF

Confidential Request for Ownership Information

ERM-14

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 OWCP/DLHWC, Charles E. Bennett Federal Building, 400 West Bay Street, Room 63A, Box 28, Jacksonville, FL 32202 within 10 day 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 | Word
Spanish | Word
Russian | Word
Vietnamese | Word

Medical Release form

2476

Request for Release of Medical Records for Oregon Workers' Compensation Claim. Used to obtain relevant medical records in the absence of a worker-signed Form 801 or 827 or if the requester is someone other than the insurer, the Director of DCBS, the injured worker, or the worker's attorney.

English | Word
Spanish | 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 (Spanish).

English | PDF

Spanish | 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 reporting

English | PDF

Spanish | 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

Request for Lost Earning form

X-4003

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

F3921

(formerly 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 | 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

Surety Bond form

F3364

The surety bond form is to be completed by a licensed bonding company when an employer chooses to use a surety bond to fulfill a security deposit requirement.

English | PDF

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

Spanish | 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

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:
    • AcordTM form: 503.373.8769
    • EAIP forms: 503.584.9805
    • Forms 801 and 827: 800.475.7785
    • Nondisabling Claims Reimbursement: 503.373.8400