a self-insured claim.
(1) What form
is used to report a self-insured worker's industrial injury or
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
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