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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.



Form
F207-005-000


 
SIF-5A Cover Sheet: Wage Calculations

Used by only self-insured employers and their representatives to calculate and report injured workers’ wages and time loss compensation rates.



Form
F207-156-000


 
SIF-5A Cover Sheet: Wage Calculations

Used by only self-insured employers and their representatives to calculate and report injured workers’ wages and time loss compensation rates.



Form
F207-156-000


 
SIF-5A Cover Sheet: Wage Calculations

Used by only self-insured employers and their representatives to calculate and report injured workers’ wages and time loss compensation rates.



Form
F207-156-000


 





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