Form 801 - Oregon Workers' Compensation

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OREGON
Workers' Compensation
Claim Form 801
Workers' Compensation Division
Notice to worker:
Failure to file a claim with your employer within 90 days of injury or within one year of learning you have
an occupational disease may result in claim denial. Please read about your rights and responsibilities on the back of this form.
Notice to employer:
Failure to report a claim to your insurance company within five days of knowledge of the claim may
result in untimely payment of time-loss benefits to the worker and a penalty to you or your insurance company. Submit the
claim even if the worker is unavailable, unable to provide information, or unable to sign the form.
Guidelines for completing the 801
Use a ballpoint pen, press firmly, and write clearly, or use a typewriter. The numbered items
below correspond to those on the 801 and may help you complete the claim form.
Worker section
7.
Enter the number of years of education you have completed (GED is 12.)
8.
If you were hospitalized past midnight for treatment and lodging, check "Yes."
Provide the type of injury (example: cut leg, broken arm).
9.
11.
Identify the body part(s) injured (example: low back, leg - right, shoulder - left, etc.).
13.
Provide the actual date of accident, if an injury, or the date your condition first required medical attention,
if an occupational disease.
15.
If "Yes," briefly describe the prior injury (example: car accident in 1995, work injury in 1996, etc.).
17.
Describe the accident as completely as possible. This will help the insurance company handling your claim.
18.
Read "Important information about your Social Security Number (SSN)," "Authorization to release medical
records," and "Caution against making false statements," on the back of the 801.
This form satisfies OSHA
Employer section
Form 101 record-
20.
A Business Identification Number (BIN) is assigned by the Oregon Department of
keeping requirements.
Revenue and is printed on your Oregon Tax Coupons (OTCs).
See reverse.
22.
FEIN is your Federal Employers Identification Number.
24-27. If you are a "worker leasing company" as defined in Oregon Revised Statute 656.850(1), the businesses you
provide workers to are your "clients." Complete this section only if your worker was injured while leased to
a client.
28.
Examples: truck manufacturing, retail grocery, log hauling, etc.
29.
Enter the payroll class code under which you report this worker's earnings to your workers' compensation insurer.
33.
Report the earliest of the following:
• the date you first knew of a claim
• the date you first knew of an accident or disease that may result in a compensable injury that requires
medical services or causes time loss, permanent disability, or death.
37.
See 24-27 above, for definition of "client."
50.
Examples: "Loading dock, north end" or "Client's office at 452 Monroe Street, Washington, D.C., 20210."
51.
Examples: acetylene cutting torch, metal plate.
52.
Example: "Cutting metal plate for flooring." (Indicate whether or not activity was part of normal job duties.)
53.
Example: "Worker stepped back to inspect work and slipped on some scrap metal. As she fell, worker brushed
against the hot metal."
56.
Check "Yes" if the worker presented a Preferred Worker Eligibility Card to you at the time of hire or you
received a "Notice of Premium Exemption" from the Workers' Compensation Division (and the injury
occurred on or before the eligibility end date on the card or notice).
Si Ud. tiene preguntas relacionadas a este formulario,
If you have questions about this form, call the
comuníquese con la División de Compensación para
Workers' Compensation Division, Benefits Section,
Trabajadores, Sección de Beneficios, en Salem al número
in Salem at (503) 947-7585, TTY: (503) 947-7993,
telefónico (503) 947-7585, TTY: (503) 947-7993,
or toll-free in Oregon:
o (llamada gratis en Oregon)
(800) 452-0288.
(800)452-0288.
801
440-801 (1/00)
WC 8468b (1-00)
UNIFORM INFORMATION SERVICES, INC.

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