Saif 801 Fillable Form PDF Details

Navigating the procedural steps following a work-related injury or illness can seem daunting for employees and employers alike. The Saif 801 form, a critical document for initiating workers' compensation claims within the framework of SAIF Corporation's requirements, serves as a starting point in this journey. Designed for the prompt reporting of occupational injuries or illnesses, this form captures essential details about the incident, from the date and time of occurrence to a description of the injury and its causation. It further delves into the worker's personal information, workplace specifics, and the immediate actions taken post-incident, such as medical treatment received. Particularly noteworthy is its inclusion of directives for both the injured worker and the employer, emphasizing responsibilities like notifying SAIF Corporation within a stipulated timeframe and maintaining records even if a claim is not filed. Additionally, the form provides guidance on navigating subsequent steps, like seeking medical treatment and understanding the implications of lost wages due to work incapacity. Moreover, it underscores the importance of accurate and truthful claim filing, highlighted by the requirement for the worker's signature under the assertion that the information provided is correct to the best of their knowledge. The form also accommodates workers with language preferences other than English, reflecting an inclusive approach toward ensuring comprehensibility and accessibility in the claims process. This initial form is part of a larger ecosystem designed to streamline the interaction between workers, employers, and SAIF Corporation, ultimately aimed at facilitating efficient and equitable resolutions to workers' compensation claims.

QuestionAnswer
Form NameSaif 801 Fillable Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessaif form 801, saif 801, corters saif 31 01 be ofeso, printable 801 form

Form Preview Example

For SAIF Customer Use

400 High St. SE, Salem, OR 97312

Area

 

 

 

Dept.

 

 

 

Shift

 

CC

CLAIM NO. SUBJECT DATE CLASS

DEFAULT DATE

EMPLOYER’S ACCOUNT NO.

Worker

Email:

saif801@saif.com

Toll-free phone:

1.800.285.8525

Toll-free FAX:

1.800.475.7785

Report of Job Injury or Illness

Workers’ compensation claim

To make a claim for a work-related injury or illness, ill out the worker portion of this form and give to your employer. If you do not intend to ile a workers’ compensation claim with SAIF Corporation, do not sign the signature line. Your employer will give you a copy.

1. Date of injury

 

2. Date you

 

3. Time you began work

 

 

 

 

a.m.

4. Regularly scheduled

DEPT USE:

or illness:

 

left work:

 

on day of injury:

 

 

 

 

 

p.m.

days off:

 

 

 

 

 

 

 

 

Emp

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Time of injury

a.m.

6. Time you

a.m.

7. Shift on

 

(from)

 

a.m.

 

p.m.

 

 

 

 

 

 

 

 

 

or illness:

p.m.

left work:

p.m.

day of injury:

 

(to)

 

a.m.

 

p.m.

M T W T F S S

Ins

 

 

 

 

 

 

 

 

 

 

Occ

8. What is your illness or injury? What part of the body? Which side? (Example: sprained right foot)

Left

Right

 

 

 

 

9. Check here if you have

 

 

 

 

 

 

 

 

 

 

 

more than one job:

 

 

 

 

 

 

 

 

 

 

 

 

Nat

 

 

 

 

 

 

 

 

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 rooing materials)

Part

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ev

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Src

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2src

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

11. Your legal name:

 

 

 

12. Worker’s language preference other than English:

13. Birthdate:

 

 

14. Gender:

 

 

 

 

 

 

 

Spanish

 

Other (please specify):

 

 

 

 

M

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. Your mailing address,

 

 

 

 

 

 

 

 

 

 

16. Home phone:

 

city, state and zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. Social Security no. (see back*):

 

 

 

 

 

18. Occupation:

 

 

 

19. Work phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. Names of witnesses:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. Name and phone number of health insurance company:

 

 

 

 

 

 

 

 

22. Name and address of health care provider who treated you for the injury or illness you

 

 

 

 

 

 

 

 

 

 

are now reporting:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26.By my signature, I am making a claim for worker’s compensation beneits. 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 Businesss 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.

27.Worker signature:

28.Completed by (please print):

Employer

29. Date:

Complete the rest of this form and give a copy of the form to the worker. Notify SAIF Corporation within ive days of knowledge of the claim. Even if the worker does not wish to ile a claim, maintain a copy of this form.

30. Employer legal

 

 

 

 

 

 

31. Phone:

 

 

 

32. FEIN:

 

 

business name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33. If worker leasing company,

 

 

 

 

 

 

 

 

 

 

34. Client

 

 

list client business name:

 

 

 

 

 

 

 

 

 

 

FEIN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

35. Address of principal place

 

 

 

 

 

 

 

 

 

 

36. Insurance

 

 

of business (not P.O. Box):

 

 

 

 

 

 

 

 

 

 

policy no.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

37. Street address from which

 

 

 

 

 

 

 

 

 

 

38. Nature of business in which worker is/was

worker is/was supervised:

 

 

 

 

 

 

ZIP:

 

 

 

supervised:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

39. Address where

 

 

 

 

 

 

 

 

 

 

 

 

 

 

event occurred:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

 

42. Were other workers injured?

Yes

No

 

43. Did injury occur during course

Unknown

Yes

No

 

 

44. OSHA 300 log case no:

 

 

 

 

 

 

and scope of job?

 

 

 

 

 

 

 

 

 

45. Date employer

 

46. Worker’s

 

 

47. Date worker

 

 

 

48. If fatal, date

 

 

knew of claim:

 

weekly wage: $

hired:

 

 

 

of death

 

 

49. Return-to-work status: Not returned

 

 

Regular

Modiied

 

 

50. If returned to modiied work,

Yes

No

 

 

 

 

Date:

Date:

 

 

is it at regular hours and wages?

 

 

 

 

 

 

 

 

51. Employer

 

 

 

 

52. Name and title

 

 

 

 

 

 

53. Date:

 

 

signature:

 

 

 

 

(please print):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

801

OSHA requirements: On the job fatalities and catastrophes must be reported to Oregon OSHA within eight hours.

801

Report any accident that results in overnight hospitalization within 24 hours to Oregon OSHA. Call 800.922.2689,

X801 4/11

503.378.3272, or Oregon Emergency Response 800.452.0311, on nights and weekends.

 

 

 

 

 

 

 

A guide for workers recently hurt on the job

The following information is provided by SAIF Corporation

400 High St. SE, Salem, OR 97312

at the request of the Workers’ Compensation Division

 

How do I ile 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, “Worker’s and Physician’s Report for Workers’ Compensation Claims,” 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:

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 off work, your health care provider must send written authorization to the insurer.

•Generally, you will not be paid for the irst three calendar days for time off work.

•You may be paid for lost wages for the irst three calendar days if you are off work for 14 consecutive days or hospitalized overnight.

•If your claim is denied within the irst 14 days, you will not be paid for any lost wages.

•Keep your employer informed about what is going on and cooperate with efforts to return you to a modiied-

–

Authorized nurse practitioners

or light-duty job.

–

Chiropractors

What if I have questions about my claim?

 

 

–

Medical doctors

• SAIF Corporation or your employer should be able

 

 

–

Naturopaths

to answer your questions. Call SAIF Corporation at

–

Oral surgeons

800.285.8525.

 

–

Osteopathic doctors

• If you have questions, concerns, or complaints, you may

also call any of the numbers below:

 

 

–

Physician assistants

Ombudsman for Injured Workers:

 

 

–

Podiatrists

An advocate for injured workers

–

Other health care providers

Toll-free: 800.927.1271

• The insurance company may enroll you in a managed care

Email: oiw.questions@state.or.us

organization at any time. If it does, you will receive more

Workers’ Compensation Compliance Section

information about your medical treatment options.

Are there limitations to my medical treatment?

Toll-free: 800.452.0288

 

• Health care providers may be limited in how long

Email: workcomp.questions@state.or.us

 

they may treat you and whether they may authorize

 

payments for time off 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.

* 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 beneits. If you have an SSN, and don’t provide it, 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: quality assessment, correct identiication and

processing of claims, compliance, research, injured worker program administration, matching data with other state agencies to measure WCD program effectiveness, 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).

440-3283 (01/10/DCBS/WCD/WEB) for distribution with X801 SAIF Corporation 1/10

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