Receiving the necessary claims forms in a timely manner provides Empire Pacific claims personnel adequate time to investigate the claimed injury or disease. Prompt reporting also discourages unwarranted litigation activity, helps get the injured worker back to work as soon as possible, and helps to maintain a positive working relationship between employer and employee and the program's administrator.

The Forms and instructions on this page can be viewed by simply clicking on the links. You will need Adobe Acrobat reader to view and print these forms. For a free download, click here:
You may then print these forms, complete the information requested, and return them to us by mail or fax.

If you have any questions regarding which forms to use, visit Which forms do I use?, or contact Empire Pacific Risk Management, Inc. at (503) 968-6300.

• Form 801 WORD/PDF - "The Worker's and Employer's Report of Occupational Injury or Disease/Illness" form is used by injured workers and employers in reporting injury or disease claims. Form 801 must be completed and returned to Empire Pacific within five (5) days of employer knowledge of the claim. Click Here for tips on filling out form 801
  
  
• Form 801 Spanish WORD/PDF - El informe de Worker's y de Employer's de lesión ocupacional o de Disease/Illness. la forma es utilizada por los trabajadores dañados y los patrones en la divulgación de demandas de lesión o de la enfermedad.
  
  
• 3283 - A Guide for Workers Recently Hurt on the Job WORD/PDF
  
  
• 3283 - Una guia para trabajadores lesionados recientemente en eltrabajo WORD/PDF
  
  
• 2476 WORD/PDF - "Request for Release of Medical Records for Oregon Workers' Compensation Claim" Used to obtain relevant medical records in the absence of a worker-signed Form 801 or 827 or if the requester is someone other than the insurer, the Director of DCBS, the injured worker, or the worker's attorney. Form 2476 is required by Empire Pacific, and should accompany Form 801.
  
  
• EPRM E1, Employee accident report WORD/PDF - The "Employee Accident Report" must be completed by the injured worker if he/she has the potential to lose time on the job, or if the employer questions the validity of the claim. This does not replace Form 801, which is required by the state of Oregon.
  
  
• EPRM S1, Supervisory Accident Investigation Report WORD/PDF - The "Supervisory Accident Investigation Report" is required by Empire Pacific if the injured worker has the potential to lose time on the job due to the injury, or if the supervisor or employer questions the validity of the claim. This form should be completed by the supervisor or employer of the injured worker.
  
  
• Sample Drug Policy /PDF
  
  
• Simple Early Return to Work Form WORD/PDF - These forms are used when an injured worker's physician has returned him or her back to work with restrictions or limitations. The work tolerance report may also be sent to the physician in order to obtain clarification if restrictions are vague.



• Spanish Modified Work Job Offer Letter WORD/PDF - This form is used when a Spanish-speaking injured worker's physician has returned him or her back to work with restrictions and the company has a light/modified duty job available.