Please rate Oregon Form 801 1-21
If you do not intend to file a workers' compensation claim with the insurance company, do not sign the signature line.
Employer: complete the rest of this form and give a copy of the form to the worker. Even if the worker does not want to file a claim, keep a copy of this form.
Insurance company: the employer acknowledges responsibility for notifying the workers' compensation insurance company within five days of knowledge of the claim.
OSHA reporting: employers must report work-related fatalities and catastrophes to Oregon OSHA either in person or by telephone within eight hours.
| Question | Answer |
|---|---|
| Form Name | Form 801 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 66 |
| Avg. time to fill out | 11 min |
| Edition | Rev 1/21 |
| Insurance company | Within five days of knowledge of the claim, the employer is responsible for notifying the workers' compensation insurance company |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | 801, Form 801, Oregon Form 801, 801 form Oregon, Report of Job Injury or Illness, workers' compensation claim |
| Official source | Form 440-801 (1/21/DCBS/WCD/WEB) |
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Please rate Oregon Form 801 1-21
