Find a workers' compensation form

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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 you can have 801 forms sent to you.	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
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.	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:
- Acord^TM form: 503.373.8769
- EAIP forms: 503.584.9805
- Forms 801 and 827: 800.475.7785
- Nondisabling Claims Reimbursement: 503.373.8400