Box #29.  Write in the agency name. The agency name may be a department name (i.e., Department of Human Services) or, it may be a sub-agency name, such as Oregon State Hospital. Use the name that matches the policy number assigned by SAIF Corporation. Your agency Safety Advisor can let you know what name to use.

Box #30:  Write in the phone number for the agency named in box #29. If this is unknown write in the phone number of the agency Safety Advisor, or manager of the injured employee. Check with your Safety Advisor to find out which name and number to use.

Box #31:  Write in the Federal ID Number (FEIN) assigned to the agency named in box #29. The FEIN corresponds to the SAIF policy number in box 35.

Box #32:  Does not apply. Leave this box number blank.

Box #33:  Does not apply. Leave this box number blank.

Box #34:  Write in the address for the agency named in box #29.

Box #35:  Write in the policy number assigned by SAIF Corporation for the agency named in box #29. If the number is not known leave this box blank.

Box #36:  Write the address of the office location to which the worker is assigned at the time of injury. OR-OSHA uses the address listed in this box to evaluate injury frequencies.

Box #37:  Write a brief description of what the agency does.

Box #38:  Write the address where the actual injury took place. This may be an intersection, mile marker, park name, geographical location, or building other than the location at which the employee usually works.

Box #39:  This box asks whether the injury was caused by failure of a machine or product, or by a person other than the injured worker. Mark the yes or no box, if you are certain. If you are uncertain leave both boxes blank.

Box #40:  Always put the class code: 9499.

Box #41:  This box asks whether other workers were injured. Answer the question yes or no, if you are certain. If you are uncertain leave both boxes blank.

Box #42:  Answer the question yes, no or unknown. Answer “yes” if you have first hand knowledge that the injury was caused by work. Otherwise, consider using the answers no and unknown. This should prompt the claims adjuster to call the person named in Box 51.

Box #43:  Write in the OSHA 300 log case number that you have assigned off of your OSHA 300 log.

Box #44:  Write in the date that you as the employer representative first knew that medical treatment was required regarding the incident or injury. If you are not sure of this date leave the box blank.

Box #45:  This box asks for the weekly wage. State employees are paid monthly. Record the salary and make sure you indicate it is a monthly wage.

Box #46:  Put the date that the worker was first hired by the agency. If the worker terminated their employment and then returned to the agency put the new hire date on the form. If this date is unclear or unknown leave the box blank.

Box #47:  Only complete if the claim is being filed due to a fatality.

Box #48:  Mark the appropriate box for return to work status and provide a date when the status occurred. The “modified” work status means that the worker returned to an assignment that is not their regular job.

Box #49:  Mark either yes or no. Answer “yes”, if the employee is truly working modified work at the same hours and wages that they were receiving prior to the injury. If an employee regularly receives differentials, overtime pay, etc., but will not receive this additional income while working the modified assignment, or their hours are changed, then answer “no”.