You may fill out this form, print it and then FAX it to 303-860-5680 ** This is a Required Field

EMPLOYEE'S INJURY REPORT FORM

University Risk Management 1800 Grant Street, Suite 700 Denver, CO 80203 Phone: 303-860-5682 Fax: 303-860-5680 CAMPUS ** Boulder Denver UCCS System DATE OF CLAIM ** DATE IF PREVIOUSLY REPORTED DATE AND TIME OF OCCURRENCE ** Date:Time:AM/PM:

PERSONAL INFORMATION

LAST NAME, FIRST NAME ** HOME ADDRESS ** CITY, STATE ** ZIP ** SOCIAL SEC # **

HOME PHONE ** AGE DATE OF BIRTH** SEX # OF DEPENDENTS YEARS OF EDUCATION

MARITAL STATUS Single    Married    Divorced    Widowed RACE Asian    White    Black    Hispanic    Don't Wish to Answer

EMPLOYMENT INFORMATION

DEPARTMENT ** DEPT. # WORK PHONE ** BOX # DATE OF HIRE

JOB TITLE JOB POSITION # YEARS IN THIS POSITION ANNUAL SALARY

SUPERVISOR NAME ** SUPERVISOR PHONE ** SUPERVISOR EMAIL

USUAL SHIFT (indicate am/pm) ** to DAYS OF THE WEEK ** Su Mo Tu We Th Fr Sa

OCCURRENCE

LOCATION OF OCCURRENCE ** WHAT JOB/ACTIVITY WERE YOU PERFORMING? **

AUTHORITY CONTACTED DATE CONTACTED PHONE

WHAT BODY PART(S) INJURED? ** WHAT TYPE OF INJURY ** (cut, needlestick, burn, etc.)?

WHAT HAPPENED TO CAUSE THIS INJURY? ** (describe how the event occurred, including other persons involved, tools, machinery, chemicals, etc.)

HOSPITAL/PHYSICIAN CONSULTED (Name/Location/Phone) DATE

TIME LOST AT WORK ** Yes    No DATE LAST WORKED ** DATE RETURNED ** ADDITIONAL COMMENTS

WITNESSES

NAME & ADDRESS BUSINESS PHONE RESIDENCE PHONE

** This is a Required Field

It is unlawful to knowingly provide false or misleading information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages.