Self-insurance forms categorized by area of economy:

To Employers

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

Substantially Similar Forms

Pension Review Coversheet

Suspension Request Coversheet

No Show Fee Request Checklist

Willful Misrepresentation Checklist

Release regarding Medical Accounts and Patient Privacy included Workers’ Compensation

Stipulation Coversheet

For Workers

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)

For Providers For Certification Services

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)

Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Restricted Liability Company (LLC) (F213-042-000)

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 - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers (F213-004-000)

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)

Miscellaneous