Self-Insured Provider's Initial Report (PIR) Order Form

Only medical providers and self-insurers should use this form to order the Provider's Initial Report (PIR) for self-insured claims. You will need to check periodically for updates to the form.

You now have 2 options for ordering PIRs. You may order: (choose one)

  • The paper forms as usual
    OR
  • Microsoft Word® (a fillable Word file will be sent electronically.)

Note: Send the completed PIR to the self-insured employer or their representative since they manage their own claims.

Order Self-Insured PIR form
Order Provider's Initial Report (PIR) form
Enter your request in the spaces below. indicates required field

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