(For a Members Site account, please contact your Account Executive)


Need access to our online OSHA 300 Log service?

Click Here!

 

Already have access? Login below!

 

Have questions or need assistance? Email Patrick Bailey, or call him at the Empire Pacific office at (503)968-6300 ext.863.

User ID
(Your email Address)
Password   Forgot your Password?
Topic Resources
Accident Investigation OSHA Resources
Aerial Lifts OSHA Resources
Asbestos Awareness – Abatement OSHA Resources
Back Injury Prevention – Material Handling OSHA Resources
Blood borne Pathogens – Universal Precautions OSHA Resources
Chain saw safety – practical OSHA Resources
Combative Residents - Dementia OSHA Resources
Confined Space – Permit & Non-Permit Care for Half Mask Respirator
Carelessness
Cargo Docks
Cartridge Respirator Limitations
Chain Saws
Chemical Hazards
Chock and Block
CO Poisoning Survival
CO Poisoning
Cold Meds and Drowsiness
Cold Weather and Propane Vehicles
Come Alongs and Hoists
Confined Space Atmospheres
Confined Space Dangers
Confined Space Entry
Crane Counterweights
Crane Operations Under Load
Craning Considerations
Cumulative Trauma Disorders
Cuts and Burns
Demolition Hazards
Do Cell Phones Cause MVAs?
Don't Gamble with Fall Arrest Equipment
Don't Get Sore at Your Computer
Drinking and Driving Holidays
Drum Handling
Eight Crane Danger Signs
Electrical Hazards: Anatomy of Accident
Electrical Hazards: High Voltage Electrical Burns
Electrical Safety: Portable Light Strings
Electrical Safety: Static Electricity
Electrical Sources in Hazardous Locations
Emergency! Where's the Fire Extinguisher?
Employee Responsibility
Everyone is Responsible for Safety
Excavation Trenching
Excavations
Extension Cord Safety
Eye Injury Prevention
Eye Protection Quiz
Eye Protection-Sun and Shade
Eye Protection
Eye Wash and Deluge Showers
Fall Arrest and Restraint Systems
Fiberglass
First Aid Kit
Flammable Liquids: Gasoline
Footwear
Forklift Fatalities
Forklift Safety: Elevating Personnel
Front End Loaders
Fueling Safety and Static Electricity
GFCIs Home and Work
Haz Mat ID System
Hazard Awareness General
Hazard Awareness
Hazard Communication Standard
Hazard Recognition
HAZCOMM vs. HAZMAT vs. HAZARDOUS WASTE What Is The Difference?
Head Injuries
Hearing Protection
Heat Stress Disorders
Heavy Equipment Safety
High Pressure Injection Equipment
Holiday Stress
Hot Water and Steam Cleaning
Housekeeping is Safe Keeping
Housekeeping
How Loud is Loud
Hydraulic Hoses
Hydroblaster
Individual Quality
Ladder Safety
Lift it Twice
Pneumatic Tools
PPE-Picking the Proper Glove
Solvents
Temporary Heating Devices

Want a Drug User on Your Team?

Workplace Electrical Safety


Downloads

Download Poster 11"x17" | Download Handout 8.5"x11"
Request a Certificate of Insurance
  1. Complete all required fields on this form marked with an *
  2. Review all items for accuracy. Double check phone/fax numbers
  3. Click the SUBMIT CERTIFICATE REQUEST button at the bottom of this form
Please note that all requests will be processed within three business days.
Name*
Phone Number*
Email*
Issue Certificate of Coverage to:
Certholder Name*
Attention
Address Line 1*
Address Line 2
City*State* Zip*
Job/Location Description:
Is the job located in a state other than Oregon?
Job/Location Description:
Waiver of Subrogation?
Special Options?--Explain below if you chose "Yes" for Special Options
Additional Comments:
Fax Options:
Please enter fax numbers below if you need this certificate faxed:

Certholder Fax Number
Member Fax Number

  

For questions, please contact your Account Executive.
EAIP Employer-at-Injury Program. Incentive program administered by insurers for employers to provide early-return-to-work programs for their injured workers.
ERTW Early Return To Work Program
Experience Rating Modification (Mod) A modifier that is expressed as a percentage and applied to an employer's premium that reflects prior loss experience. A company with an experience rating below 1.00 will pay less premium than average; a company with a rating above 1.00 will pay more premium.
IBNR Incurred But Not Reported
MCO Managed Care Organization
OSHA Occupational Safety and Health Administration
Preferred Workers Subject Oregon worker who, because of permanent disability resulting from a compensable injury or occupational disease, is unable to return to his or her previous (regular) employment and meets the Preferred Worker Program eligibility criteria for assistance.
PPD Permanent Partial Disability
SIG Self-Insured Group
TTD Total Temporary Disability
Step #1 In every case of workplace injury, appoint someone to act as your company's point of contact. This person will coordinate activity between your injured employee and our claims adjuster. Make sure that this person's name and contact information accompany all correspondence forwarded to Empire Pacific and/or the State.
Step #2 In every case of workplace injury, you are required to: A) file Form 801 (First Report Occupational Injury or Disease). You must forward the form to Empire Pacific so that the claims adjuster receives it within 5 calendar days of the date you learned about the injury, and B) complete and forward Form 2476 (Request for Release of Medical Records for Oregon Workers' Compensation Claim). This form must also be forwarded to Empire Pacific so that the claims adjuster receives it within 5 calendar days of the date you learned about the injury. Please Note: Even if the Form 801 is not signed by the injured worker, it is most important to send the form to Empire Pacific. Do not hold on to the form waiting for the worker to sign it.
Step #3 If your employee's injuries are such that they may lose time from work or you or your supervisor question the validity of the injury, in addition to Steps 1 and 2, you must complete and forward two additional forms: Form EPRM S1 (Supervisory Accident Investigation Report) and Form EPRM E1 (Employee Accident Report). These forms must also be forwarded to Empire Pacific so that the claims adjuster receives it in time to properly investigate and adjust the claim.
Step #4 If your injured employee was required to stay overnight in a hospital as a result of their injury, you: A) are required by law to call either (800) 922-2689 or (503) 378-3272 (Oregon Department of Consumer and Business Services or Oregon OSHA) within 24 Hours of the time of injury, B) must call (503) 968-6300 (Empire Pacific Risk Management) immediately thereafter to report the details of the injury, and C) must alsocomplete Steps 1 and 2 - forward Form 801 so that the claims adjuster receives it within 5 calendar days of the date you learned about the injury.
Step #5 If your employee has died as a result of a workplace accident, you: A) are required by law to call either (800) 922-2689 or (503) 378-3272 (Oregon Department of Consumer and Business Services or Oregon OSHA) within 8 Hours of the time of death, B) must call (503) 968-6300 (Empire Pacific Risk Management) immediately thereafter to report the details of the accident, and C) must also complete Steps 1 and 2 - forward Form 801 so that the claims adjuster receives it within 5 calendar days of the date you learned about the injury.
Step #1: Respond to the injured employee
  • Immediate care other than first aid
  • Hospitalization (not serious)
  • Hospitalization (serious or life threatening)

Render treatment

  • Communicate w/employee immediately; notify family if warranted
  • Communicate w/employee and immediate family if warranted

Determine restrictions, if any

  • Notify OR-OSHA within 24 hours if hospitalized overnight or if amputation occurs (503) 378-3272
  • Communicate w/doctor and hospital to determine the employee's condition

Have employee complete Employee Accident Report

  • Communicate w/doctor to determine diagnosis to include any restrictions
  • Notify Empire Pacific Risk Management, Inc. for immediate case management

Return employee to work

  • Implement return to work process; immediately notify Empire Pacific Risk Management, Inc.
  • Repeat communication process with both doctor and Empire Pacific Risk Management, Inc. within 24 hours

Have employee complete Employee Accident Report upon return

Notify OR-OSHA within 8 hours of any fatality or catastrophe (3 or more employees hospitalized

Step #2: Initiate accident investigation process
  • Inspect the accident site (take photographs if you can)
  • Interview all witnesses and secure statements
  • Identify cause(s) of accident
  • Secure area and/or equipment if warranted
  • Complete Supervisory Accident Investigation Report
Step #3: Report accident to Empire Pacific Risk Management, Inc.
  • Complete First Report of Occupational Injury (Oregon Form 801)
  • Mail or fax along with supporting documentation (forms, statements, etc.)*
  • As indicated in Step 1, call Empire Pacific Risk Management, Inc. immediately to report if the injury is serious or life threatening

    *Accidents should always be reported immediately, do not delay reporting solely for the purpose of not having all information relative to the accident. Subsequent information can always be forwarded as received

Serious or Third Party Accident Guidelines

Although most accidents that occur are not of a serious nature, there are times when injuries can be serious or even life threatening. Listed below are the types of injuries that require immediate reporting to Empire Pacific Risk Management, Inc.:

  • Fatalities
  • Spinal cord injuries
  • Serious burn injuries
  • Head injuries involving fractures or loss of consciousness
  • Amputation of a major limb
  • Electrocution

There are also circumstances where other persons, circumstances or elements may have placed your employees at an increased risk. In these situations, it is important to have all relative information available to us. It is also of extreme importance that these accidents are well documented. These accidents should be investigated thoroughly and reported immediately:

  • Accidents involving faulty or malfunctioning equipment or machinery
  • Accidents where other contractors or subcontractors are controlling the work site or project
  • Accidents involving two or more employees
  • Accidents that occur in areas that are deemed hazardous
 
 

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.

 
 


Download Form 801: Report of Job Injury or Illness: