Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form

Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form - (Forms/Publications)
Document Information
  Get help downloading & printing files.   How to complete a fillable form.
Title Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form (A fillable form - 136 KB PDF)
Description Used by self-insured employers and third party administrators to enroll for participation in the Self Insurance Electronic Data Reporting System (SIEDRS). F207-197-000 is SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request.
Detail
Form number F207-193-000
Availability
Online only. See document above to download.
Keywords employer enrollment, industrial insurance, self insurer, self-insurer, submission, submitter, third party administrator enrollment, tpa enrollment, worker's compensation, workers compensation, workers' compensation
Languages English
Valid dates 02-2008
Contact information Self-Insurance
Web pages Self-Insured Employers

End of main content, page footer follows.

Access Washington official state portal

© Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.