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Washington Workers' Compensation Legal Library

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296-15-405 Filing a self-insured claim.

(1) What form is used to report a self-insured worker's industrial injury or occupational illness?

The reporting form for a self-insured worker's industrial injury or occupational illness is the Self-Insurer Accident Report (SIF-2) L&I form F207-002-000. Self-insurers must obtain these forms from the department and must report their workers' industrial injuries and illnesses to the department with SIF-2s. The department tracks the claim numbers assigned to self-insurers.

When notified of injury or illness, the self-insurer must provide the worker with this prenumbered form and assistance in filing a claim. The self-insurer must provide the worker the designated copy of the completed SIF-2 (which includes an explanation of the worker's rights and responsibilities) within five working days of completion.

(2) What form does a doctor use to report a self-insured worker's industrial accident or occupational illness?

Physicians should report a self-insured claim with a Physician's Initial Report (PIR) L&I form F207-028-000 when a self-insured worker has an industrial injury or is notified of an occupational illness. Replacements are acceptable.

[Statutory Authority: RCW 51.32.190(6), 51.32.055 (8)(a) and (9)(a). 98-24-121, § 296-15-405, filed 12/2/98, effective 1/2/99.]

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