Provider's Initial Report (PIR)

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Provider's Initial Report (PIR)

(23 KB PDF)

Provider's Initial Report (PIR)

(129 KB DOC)

Provider's Initial Report (PIR)

(42 KB DOC)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.

Número del formulario F207-028-000
Disponibilidad solicítelo
Palabras claves accident report, claim information, claims coverage, diseases, first report, industrial insurance, medical forms, medical treatment, occupational diseases, occupational injuries, Provider, Providers report, report of accident, report of injury or occupational disease, reporting accidents, self-insured, worker's compensation, workers compensation, workers' compensation
Idiomas English
Fechas válidas 01-2014
Contacto Self-Insurance
Páginas de Internet Self Insurance

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