Department of Labor & Industries Self Insurance Section PO Box 44892 Olympia WA 98504-4892 Employer INITIAL: On the date first time loss is paid INTERLOCUTORY ORDER REQUEST FINAL: On the date claim is closed by employer FINAL: On the date final determination is requested Claimant Date of injury Claim arrival date Date first treated Last day worked SIF-5 UBI SI REPORT ON OCCUPATIONAL INJURY OR DISEASE Account ID Service Co. FOR FINAL SIF-5: If the employer stopped contributing to health care benefits, list the date the employer's payment ended for each type. Medical: Dental: Vision: Claim No. (ALL INFORMATION MUST BE COMPLETED) SUPPLEMENTAL: Upon Department Request SUPPLEMENTAL: Correction of Previous SIF 5 WAGE ORDER requested (SIF-5A and appropriate documentation attached) OVERPAYMENT ORDER REQ. (SIF-5A and appropriate documentation attached) Address Date of lst payment Date released for work Date returned to work COMPENSATION PAID through through through through @$ @$ @$ @$ Total number of time loss days paid Total number of LEP days paid Is there a permanent impairment? Has time loss exceeded 90 days? Return to work priority (A-I) Rehab Outcome Report Type Cost Attending physician Address City Remarks State ZIP From From From From Time Loss Compensation Loss of Earning Power per per per per days totaling days totaling days totaling days totaling Total time loss amount paid $ Total LEP amount paid $ (see attachment for documentation) Is condition medically fixed? Has claimant returned to same employer? E.A.R. approval date Code # Complete for Claim Closure only Time loss Treatment only Notice: At time of final determination, no further medical services are authorized subsequent to the date of this report. L&I use only All requirements for closure of this claim by the self-insured employer have been met and are documented in our file. Final determination request of the Department of Labor and Industries. Copies of medical report and pertinent information attached. I hereby certify that I have addressed the value of the employer's contribution to any health insurance benefits and included it in the time loss rate if appropriate. Date Authorized Representative F207-005-000 SIF-5 si report on occupational injury or diseases 09-2007 NOTE: SUBMIT 1 COPY OF THIS FORM TO THE CLAIMANT AND 1 COPY TO LABOR & INDUSTRIES American LegalNet, Inc. www.FormsWorkflow.com