Self-Insurance Report of Occupational Injury or Disease (SIF-5)

Document Information
  How to complete a fillable form.
Title Self-Insurance Report of Occupational Injury or Disease (SIF-5)

Used by only self-insured employers or their representatives to report initial time loss payments or to request interlocutory, wage, overpayment or closure orders.

Document number F207-005-000
How to get this document
Alt Language(s)
Valid dates 09/2007
Contact information Claims for Job Injuries, Managing Injured Workers' Claims, Self-Insurance
Related information

SIF-5A Cover Sheet: Wage Calculations

Websites Checklists & Instructions for self-insurers, Insurance for Business, Self-Insured Employers

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