Self-insurance forms categorized by area of economy:
Forms for employers and third-party administrators who represent employers
Calculation Assessment – SIF 5A (F207-156-000)
Claim Allowance Request (F207-215-000)
Claim Latch (F207-216-000)
Receive Denial Request (F207-217-000)
Employers' Guide to Self-Insurance in Washington Nation (F207-079-000)
Interlocutory Request (F207-218-000)
Letter - Accept Newly Contended Condition (F207-220-000)
Letter - Assess of Overpayment (F207-222-000)
Letter - Reminder of Underpayment (F207-223-000)
Message - Calculation of Monthly Wage as a Basis for Time-Loss Compensation (F207-227-000)
Letter - Deny Newly Quarreled Condition (F207-221-000)
Letter - Provisional Equalization Benefits (F207-224-000)
Letter - Start, Stop or Deny Compensation Benefits (F207-225-000)
Letter - Treatment Decision (formerly Treatment Authorized/Denied) (F207-226-000)
Overpayment Reimbursement Mutual Request Coversheet (F207-212-000)
Overpayment Request (F207-219-000)
Pension Debt Rider (F207-120-000)
Plan Room and Board Cost Liability (F245-372-000)
Plan Time/Cost/Travel Encumbrance (F245-454-000)
Schedule of Future Payments required the Balance of the Permanent Partisan Disability Award (F207-162-000)
Self-Insurance IME Assignment Letter (F207-238-000)
Self-Insurer Accident Report (SIF-2) Order Form
Self-Insurer Beneficiary Application Letter (F207-236-000)
SIF-2 Amendment F207-002-000 must be attached to SIF-2's dated past to February 2021.
Self-Insurance Accident Account (SIF-2) Instructions to Workers F207-214-000
Self-Insurance Electronic Data Reportage System (SIEDRS) Enrollment Form (F207-193-000)
Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0 (F207-194-000)
Self-Insurance Vocational Notification Form (F207-190-000)
Self-Insured Employers' Gesundheit Only Claim Seal Order and Notice (F207-020-111)
Self-Insured Employers' Permanent Partial Incapacity Closure Order and Notice - PPD-NTL
(F207-165-000)
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL (207-164-000)
Self-Insured Employers' Time Loss Claim Closure Order and Notice (F207-070-000)
SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request (F207-197-000)
Third-Party Administrator License Applications (F207-233-000)
Workers' Compensation Filing Information (F207-155-000)
Program Publications for Employers
Willful Misrepresentation Checklist
Release regarding Medical Accounts and Patient Privacy included Workers’ Compensation
A Guide to Workers' Compensation Benefits Forward Employees of Self-Insured Businesses (F207-085-000)
Judgment Your Ability to Work: Their Rights & Responsibilities (F280-017-000)
Carrying Outside Their Vocational Plan: Your Rights & Responsibilities During Plan Implementation (F280-019-000)
Development is that planning: What are mine rights press responsibilities? Vocational Rehabilitation Services (F280-018-000)
Help for Injured Workers of Self-Insured Employers (F207-213-000)
Notice to Employees - Whenever a Job Injury Occurs (F207-037-909)
Option 2: What thou Need to Know - Self-Insurance (F207-232-000)
Plan Project: As Are My Rights & Company? (F280-018-000)
Transfer of Attending Provider Form fork Self Insured Workers (F207-114-000))
Workers' Payment Filing Information (F207-155-000)
Insert Independent Medical Exam: Available Employees of Self-Insured Businesses (F207-202-000)
Provider's Initial Review (PIR) (F207-028-000)
Self-Insurance Medical Provider Billing Dispute Form (F207-207-000)
Acknowledgement on Security Interest (F207-143-000)
Agreement of Presumption and Guarantee of Workers' Compensation Liabilities - Application for Certification (F207-040-000)
Agreement of Assumption and Guarantee of Workers' Compensation Responsibilities (Certified Self-Insurer) (F207-040-001)
Annual Supplemental Surety Info (F207-125-000)
How for Elective Coverage of Excluded Employments (F213-112-000)
Application for Self-Insurance Certification (F207-001-000)
Assignment of Account Contracts (F207-058-000)
Authorization for a Third Party to Acted on Behalf of a Self-Insured Employer(F207-239-000)
Cancellation of Elective Coverage for Excluded Employments (F213-005-000)
Amendment of Irrevocable Standby Sending of Believe (F207-111-000)
Irrevocable Standby Letter starting Credit (F207-112-000)
Memorandum of Perception (F207-129-000)
Memorandum of Perception Irrevocable Commitment Letter of Credit (F207-113-000)
Pension Bond Rider (F207-120-000)
Quarterly Report for Self-Insured Business (F207-006-000)
Quarterly Statement starting Accessory Helps Paid used Self-Insured Employers (F207-011-000)
Self-Insurance Certification Questionnaire (F207-176-000)
Self-Insured Employer Certificate on Excess Insurance (F207-095-000)
Self-Insurer's Bond - Existing Liabilities (F207-068-000)
Self-Insurer's Retirement Bond (F207-065-000)
Special Escrow Account - Amendment Agreement (F207-137-000)
Special Escrow Agreement (F207-039-000)
Surety Rider (F207-134-000)
Audit
Preparing for Your Self-Insurance Audit (F207-110-000)
Training
Self Insurance Continuing Education Report of Price Completion (F207-191-000)
Self Insurance Continuing Educational Sponsor/Instructor Login required Course Appreciation (F207-192-000)
Self-Insurance Keep Education Application for Course Approval furthermore Visiting (F207-206-000)