Fillable Report of Job Injury or Illness Workers compensation (SAIF)

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Report of Job Injury or Illness Workers compensation (SAIF)

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The Report of Job Injury or Illness Workers compensation (SAIF) form is 1 page long and contains:

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  • 11 check-boxes
  • 79 other fields

Country of origin: US
File type: PDF

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If modied work, is it regular hours and wages?
Regular Modied
Date: Date:
10. What caused it? What were you doing? Include vehicle, machinery, or tool used. (Example: Fell 10 feet when climbing an extension ladder carrying a 40-pound box of roong materials)
52. Date:51. Name and title
(please print):
50. Employer
signature:
8. What is your illness or injury? What part of the body? Which side? (Example: sprained right foot)
Left
Right
To make a claim for a work-related injury or illness, ll out this form and give to your employer.
If you do not intend to le a workers’ compensation claim with SAIF, do not sign the signature line. Your employer will give you a copy.
1. Date of injury
or illness:
2. Date you
left work:
3. Time you began work
on day of injury:
4. Regularly scheduled
days o:
M T W T F S S
5. Time of injury
or illness:
7. Shift on (from)
day of injury: (to)
6. Time you
left work:
9. Check here if you have
more than one job:
13. Birthdate:
11. Your legal name:
14. Gender:
M F
12. Language preference:
15. Your mailing address: City: State: ZIP: 16. Mobile/home phone:
18. Work phone:
20. Your email address (Optional):
17. Occupation:
19. Names of witnesses:
21. Name and phone number of health insurance company:
23. Have you previously injured this body part? Yes
No
24. Were you hospitalized overnight as an inpatient? Yes
No
25. Were you treated in the emergency room? Yes
No
22. Name and address of health care provider who treated you for the injury or illness you
are now reporting:
26. By my signature, I am making a claim for worker’s compensation benets. The above information is true to the best of my knowledge and belief. I authorize health care providers and other custodians of claim records to
release relevant medical records to the workers’ compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services. Notice: Relevant medical records include records
of prior treatment for the same conditions or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and alcohol treatment records, and other
records protected by state and federal law requires separate authorization. I understand I have a right to see a health care provider of my choice subject to certain restrictions under ORS 656.260 and ORS 656.325.
27. Worker
signature:
28. Completed by
(please print):
29. Date:
Employer at time of injury
Complete the rest of this form and give a copy of the form to the worker. If the worker is unavailable, complete with available information.
Notify SAIF within ve days of knowledge of the claim. Even if the worker does not wish to le a claim, maintain a copy of this form.
31. Phone: 32. FEIN:
34. Client
FEIN:
36. Insurance
policy no.:
38. Nature of business in which worker is/was
supervised:
39. Address where
event occurred:
35. Address of principal place
of business (not P.O. Box):
37. Street address from which
worker is/was supervised: ZIP:
33. If worker leasing company,
list client business name:
30. Employer legal
business name:
40. Was injury caused by failure of a machine or product, or by a person other than the injured worker? Yes
No
41. Class code:
44. OSHA 300 log case no:
42. Were other workers injured? Yes
No
43. Did injury occur during course Unknown Yes
No
and scope of job?
45. Date employer
knew of claim:
46. Worker’s
weekly wage: $
47. Date worker
hired:
48. If fatal, date
of death
49. Return-to-work status: Not returned
801
Form 801 12.20
OSHA requirements: Employers must report work-related fatalities and catastrophes to Oregon OSHA either in person or by telephone within eight hours. In addition,
employers must report any in-patient hospitalization, loss of an eye, and any amputation or avulsion that results in bone or cartilage loss to Oregon OSHA within 24 hours.
See OAR 437-001-0704. Call 800.922.2689 (toll-free), 503.378.3272, or Oregon Emergency Response, 800.452.0311 (toll-free), on nights and weekends.
*
This form was modied by SAIF Corporation, and has been approved for use by the Oregon Workers’ Compensation Division.
Information ABOVE this line: date of death, if death occurred; and Oregon OSHA case log number must be released to an authorized worker representative upon request.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
Yes No
By my signature, I acknowledge I am responsible for notifying my workers’ compensation insurance company within ve days of knowledge of the claim. I understand I may not restrict the worker’s choice of or access to a health
care provider. If I do, it could result in civil penalties under ORS 656.260.
/ /
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DEPT USE:
Emp
Ins
Occ
Nat
Part
Ev
Src
2src
400 High St. SE
Salem, OR 97312
Email: saif801@saif.com
Toll-free phone: 1.800.285.8525
Toll-free FAX: 1.800.475.7785
CLAIM NO.
SUBJECT DATE
CLASS
DEFAULT DATE
EMPLOYER’S
ACCOUNT NO.
Report of Job Injury
or Illness
*
Workers’ compensation claim
For SAIF Customer Use
Area
|
|
Dept.
Shift CC
RESET
PRINT
A guide for workers recently hurt on the job
The following information is provided by SAIF at the request of the
Workers’ Compensation Division
400 HIGH ST. SE, SALEM, OR 97312
Form 3283* | SAIF 12.20 (440-3283, 01/21/DCBS/WCD/WEB) for distribution with Form 801.
*This form was modied by SAIF Corporation, and has been approved for use by the Oregon Workers’ Compensation Division.
Do I have to provide my Social Security number on Forms 801 and 827? What will it be used for?
You do not need to have an SSN to get workers’ compensation benets. If you have an SSN, the Workers’ Compensation Division
(WCD) of the Department of Consumer and Business Services will get it from your employer, the workers’ compensation insurer,
or other sources. WCD may use your SSN for the following: quality assessment, correct identication and processing of claims,
compliance, research, injured worker program administration, matching data with other state agencies to measure WCD program
eectiveness, injury prevention activities, and to provide to federal agencies in the Medicare program for their use as required by federal
law. The following laws authorize WCD to get your SSN: the Privacy Act of 1974, 5 USC § 552a, Section (7)(a)(2)(B); Oregon Revised
Statutes chapter 656; and Oregon Administrative Rules chapter 436 (Workers’ Compensation Board Administrative Order No. 4-1967).
How do I le a claim?
• Notify your employer and a health care provider of your
choice about your job-related injury or illness as soon as
possible. Your employer cannot choose your health care
provider for you
• Ask your employer the name of its workers’ compensation
insurer.
• Complete Form 801, “Report of Job Injury or Illness,”
available from your employer and Form 827, “Workers’
and Health Care Provider’s Report for Workers’
Compensation Claim,” available from your health care
provider.
How do I get medical treatment?
• You may receive medical treatment from the health care
provider of your choice, including:
– Authorized nurse practitioners
– Chiropractic physicians
– Medical doctors
– Naturopathic physicians
– Oral surgeons
– Osteopathic physicians
– Physician assistants
– Podiatric physicians
– Other health care providers
• The insurance company may enroll you in a managed care
organization at any time. If it does, you will receive more
information about your medical treatment options.
Are there limitations to my medical treatment?
• Health care providers may be limited in how long they
may treat you and whether they may authorize payments
for time o work. Check with your health care provider
about any limitations that may apply.
• If your claim is denied, you may have to pay for your
medical treatment.
If I can’t work, will I receive payments for
lost wages?
• You may be unable to work due to your job-related
injury or illness. In order for you to receive payments
for time o work, your health care provider must send
written authorization to the insurer.
• Generally, you will not be paid for the rst three calendar
days for time o work.
• You may be paid for lost wages for the rst three
calendar days if you are o work for 14 consecutive days
or hospitalized overnight.
• If your claim is denied within the rst 14 days, you will
not be paid for any lost wages.
• Keep your employer informed about what is going on
and cooperate with eorts to return you to a modied-
or light-duty job.
What if I have questions about my claim?
• SAIF or your employer should be able to answer
your questions. Call SAIF at 800.285.8525.
• If you have questions, concerns, or complaints,
you may also call any of the numbers below:
Ombudsman for Injured Workers:
(an advocate for injured workers)
Toll-free: 800.927.1271
Email: oiw.questions@oregon.gov
Workers’ Compensation Resolution Section
Toll-free: 800.452.0288
Email: workcomp.questions@oregon.gov
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Report of Job Injury or Illness Workers compensation (SAIF)

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Completed 26 March 2021

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