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

Self-Insurance Report of Occupational Injury or Disease (SIF-5) - (Forms/Publications)
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Title Self-Insurance Report of Occupational Injury or Disease (SIF-5) (A fillable form - 169 KB PDF)

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 number F207-005-000
Online only. See document above to download.
Keywords claim information, claims, closure, diseases, industrial insurance, interlocutory, occupational diseases, occupational injuries, report injury, report of accident, reporting accidents, self insurance, self insurer, self-insurer, SIF5, time loss compensation, time-loss compensation, wages, worker's compensation, workers compensation, workers' compensation
Languages English
Valid dates 09-2007
Contact information Managing Injured Workers' Claims
Claims for Job Injuries
Related information

SIF-5A Cover Sheet: Wage Calculations

Web pages Self-Insured Employers
Insurance for Business
Checklists & Instructions for self-insurers

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