The 801 form. Our forms can be filled out and submitted electronically (through Business Online), or filled out online and then printed and emailed, mailed, or faxed to us. (Don't forget to keep a copy.) And be sure to have the employee sign it—it helps us obtain relevant medical records and speeds up the decision-making process.

The undersigned declares under penalty of perjury, and the penalties imposed by law for the submission of a materially false or fraudulent instrument, that the undersigned is authorized to make this request; that the statements contained herein are true and correct; and that tax clearance was not obtained by providing false or fraudulent informa...

Tell your employer about your work-related injury or illness right away. Fill out Form 801 “Report of Job Injury or Illness” and turn it in to your employer. Your employer should send it to its workers’ compensation insurance carrier within five days of your notice. Your employer should provide you this form.

To make a claim for a work-related injury or illness, fill out this form and give to your employer. If you do not intend to file a workers’ compensation claim with SAIF, do not sign the signature line. Your employer will give you a copy. 1. Date of injury or illness: 2. Date you left work: 3. Time you began work on day of injury: 4. Regularly ...

Instructions for Form 801 - Application for Reinstatement and Request to Set Aside Tax Forfeiture. Access Form 801 (PDF) | Access Form 801 (Word) Additional Instruction Formats: PDF Instructions | Word Instructions. The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant code provisions.

Form 801 is your receipt that you gave notice of a claim. Keep a copy as your record. Your employer is required to submit your claim to its insurer within five days. The insurer must notify you of its acceptance or denial of your claim within 60 days after the date your employer knows of your claim. If your employer is self-insured, the

Customized specifically for SAIF customers. When you become aware of an on-the-job injury, complete the 801 form and submit it electronically by logging into your online account, or print it and submit it by email, fax, or mail as soon as possible. Be sure to make copies for yourself and your worker. Learn more about reporting a workplace injury.

This form may be used to complete the final step for reinstating a domestic or foreign filing entity that has been forfeited or revoked by the secretary of state under chapter 171 of the Texas Tax Code.

• Complete Form 801, “Report of Job Injury or Illness,” available from your employer and Form 827, “Worker’s and Physician’s Report for Workers’ Compensation

OSHA requirements: On the job fatalities and catastrophes must be reported to OR-OSHA within eight 801 hours. Report any accident that results in overnight hospitalization within 24 hours to OR-OSHA. Call (800) 922-2689, (503) 378-3272, or Oregon Emergency Response (800) 452-0311, on nights and weekends. 40. Class code: 801 p.m. p.m. (from) (to ...