Self-insurance forms categorized by area of business:

For Employers

Forms for employers & the third-party administrators who represent employers:

Calculation Rate – SIF 5A (F207-156-000)

Claim Allowance Request (F207-215-000)

Claim Closure (F207-216-000)

Claim Denial Request (F207-217-000)

Employers' Guide to Self-Insurance in Washington State (F207-079-000)

Interlocutory Request (F207-218-000)

Letter - Accept Newly Contended Condition (F207-220-000)

Letter - Assessment of Overpayment (F207-222-000)

Letter - Notice of Underpayment (F207-223-000)

Letter - Calculation of Monthly Wage as a Basis for Time-Loss Compensation (F207-227-000)

Letter - Deny Newly Contended Condition (F207-221-000)

Letter - Provisional Compensation Benefits (F207-224-000)

Letter - Start, Stop or Deny Compensation Benefits (F207-225-000)

Letter - Treatment Decision (formerly Treatment Authorized/Denied) (F207-226-000)

Overpayment Reimbursement Fund Request Coversheet (F207-212-000)

Overpayment Request (F207-219-000)

Pension Bond Rider (F207-120-000)

Plan Room and Board Cost Encumbrance (F245-372-000)

Plan Time/Cost/Travel Encumbrance (F245-454-000)

Schedule of Future Payments for the Balance of the Permanent Partial Disability Award (F207-162-000)

Self-Insurer Accident Report (SIF-2) Order Form

SIF-2 Addendum F207-002-000 must be attached to SIF-2's dated prior to  February 2021.

Self-Insurance Accident Report (SIF-2) Instructions for Workers
F207-214-214 (Cambodian)
F207-214-255 (Korean)
F207-214-294 (Russian)
F207-214-999 (Spanish)
F207-214-319 (Vietnamese)
F207-214-220 (Chinese Simplified)
F207-214-221 (Chinese Traditional)
F207-214-303 (Somali)

Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form (F207-193-000)

Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0 (F207-194-000)

Self-Insurance Vocational Reporting Form (F207-190-000)

Self-Insured Employers' Medical Only Claim Closure Order and Notice
F207-020-111 (English)
F207-020-999 (Spanish)

Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL
F207-165-000 (English)
F207-165-999 (Spanish)

Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL
F207-164-000 (English)
F207-164-999 (Spanish)

Self-Insured Employers' Time Loss Claim Closure Order and Notice
F207-070-000 (English)
F207-070-999 (Spanish)

SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request (F207-197-000)

Third-Party Administrator License Application (F207-233-000) Coming soon 

Workers' Compensation Filing Information
F207-155-000 (English)
F207-155-999 (Spanish)

PROGRAM PUBLICATIONS FOR EMPLOYERS
Substantially Similar Forms
Pension Review Coversheet
Suspension Request Coversheet
No Show Fee Request Checklist
Willful Misrepresentation Checklist
Release of Medical Records and Patient Privacy in Workers’ Compensation

For Workers

A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses (online ordering)
F207-085-000 (English)
F207-085-999 (Spanish)

Assessing Your Ability to Work: Your Rights & Responsibilities
F280-017-000 (English)
F280-017-999 (Spanish)

Carrying Out Your Vocational Plan: Your Rights & Responsibilities During Plan Implementation (F280-019-000)

Development of the plan: What are my rights and responsibilities? Vocational Rehabilitation Services (online ordering)
F280-018-000 (English)
F280-018-999 (Spanish)

Help for Injured Workers of Self-Insured Employers (online ordering)
F207-213-000 (English)
F207-213-999 (Spanish)

Notice to Employees - If a Job Injury Occurs (online ordering)
F207-037-909 (English/Spanish)
F207-037-214 (Cambodian)
F207-037-255 (Korean)
F207-037-294 (Russian)
F207-037-319 (Vietnamese)
F207-037-220 (Chinese Simplified)
F207-037-221 (Chinese Traditional)
F207-037-303 (Somali)

Option 2: What you Need to Know - Self-Insurance (F207-232-000)
F207-232-000 (English)
F207-232-999 (Spanish)

Plan Development: What Are My Rights & Responsibilities? (F280-018-000)

Transfer of Attending Provider Form for Self Insured Workers (online ordering)
F207-114-000 (English)
F207-114-999 (Spanish)

Workers' Compensation Filing Information
F207-155-000 (English)
F207-155-999 (Spanish)

Your Independent Medical Exam: For Employees of Self-Insured Businesses (online ordering)
F207-202-000 (English)
F207-202-255 (Korean)
F207-202-999 (Spanish)

For Providers For Certification Services

Acknowledgement of Security Interest (F207-143-000)

Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification (F207-040-000)

Annual Supplemental Surety Information (F207-125-000)

Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC) (F213-042-000)

Application for Elective Coverage of Excluded Employments (F213-112-000)

Application for Self-Insurance Certification (F207-001-000)

Assignment of Account Agreement (F207-058-000)

Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers (F213-004-000)

Cancellation of Elective Coverage for Excluded Employments (F213-005-000)

Amendment of Irrevocable Standby Letter of Credit (F207-111-000)

Irrevocable Standby Letter of Credit (F207-112-000)

Memorandum of Understanding (F207-129-000)

Memorandum of Understanding Irrevocable Standby Letter of Credit (F207-113-000)

Pension Bond Rider (F207-120-000)

Quarterly Report for Self-Insured Business (F207-006-000)

Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers (F207-011-000)

Self-Insurance Certification Questionnaire (F207-176-000)

Self-Insured Employer Certificate of Excess Insurance (F207-095-000)

Self-Insurer's Bond - Existing Liabilities (F207-068-000)

Self-Insurer's Pension Bond (F207-065-000)

Special Escrow Account - Amendment Agreement (F207-137-000)

Special Escrow Agreement (F207-039-000)

Surety Rider (F207-134-000)

Miscellaneous