Filing 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
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