All underlined fields are required
Report of any employee injury or illness (whether occurring during the course of employment or not).
Claim for injuries sustained by employees of contractors working on projects on behalf of the University of Michigan.
Claim for alleged damage or losses due to administrative decisions within the University. Examples include discrimination, harassment, wrongful termination, breach of contract, etc.
Losses associated with IT security issues. Examples include cyber attacks, hacking, phishing, HIPPA violations, etc.
Claim for losses associated with an injury or property damage to non-employees.
Claim for damage or losses of University of Michigan property. Examples include weather related damage (tornadoes, floods, etc.), accidents or dishonesty.
Claim for personal injuries or property damage involving University of Michigan owned or leased vehicles.
A copy of this submitted information will be emailed to the employee and supervisor. If you are not the employee or supervisor reporting this event and would like to receive a copy of this information emailed to you please enter your email address here.
For work related injuries or illnesses, State law requires that employers provide medical care at a designated facility for employees who sustain work-related injuries or illnesses. During the first 28 days, employees are required to treat at a University-designated medical facility. If you need information about a designated facility, please call Work Connections or refer to our website at http://www.workconnections.umich.edu For serious injuries, please contact Work Connections immediately at (734) 615-0643.
If known, please provide the social security number. It is used to meet federal and/or state reporting requirements.