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In all cases, regardless of the severity
of the injury, Form 801 must be completed
and returned to Empire Pacific within
5 days of employer knowledge of the injury.
Form 2476 should also be completed by
the injured worker in all cases, and,
if possible, should accompany Form 801.
This helps us provide and maintain complete
and accurate information on the injured
worker throughout the claim process.
If there is the potential of time lost
due to the injury, or if the employer
questions the validity of a claim, Form
EPRM S1, Supervisory Accident Investigation
Report, and Form EPRM E1, Employee
Accident Report, should be completed
and returned to Empire Pacific as soon
as possible. If you are unsure of how
an accident or injury occurred, simply
state "unknown" on the form.
No other explanation is necessary.
If you have any questions regarding which
forms you should use, or if you need any
additional assistance in completing the
necessary forms, please contact our Claims
Department by calling (503) 968-6300.
HOW
DO I FILE A NEW CLAIM?
CLAIM
REPORTING GUIDELINES
VIEW ALL
CLAIM FORMS
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