Self-insurance forms categorized by area of business:

For Employers

Forms for employers and 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-Insurance IME Assignment Letter (F207-238-000)

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

Self-Insurer Beneficiary Application Letter (F207-236-000)

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 F207-214-000

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) 

Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL

Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL (207-164-000)

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

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

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

Workers' Compensation Filing Information (F207-155-000) 

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

Stipulation Coversheet

For Workers

A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses (F207-085-000) 

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

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 (F280-018-000)

Help for Injured Workers of Self-Insured Employers (F207-213-000) 

Notice to Employees - If a Job Injury Occurs (F207-037-909)

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

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

Transfer of Attending Provider Form for Self Insured Workers (F207-114-000)) 

Workers' Compensation Filing Information (F207-155-000)

Your Independent Medical Exam: For Employees of Self-Insured Businesses (F207-202-000)

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)

Authorization for a Third Party to Act on Behalf of a Self-Insured Employer(F207-239-000)

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)