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.
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For work related injuries or illnesses, State Law requires the employer to provide medical care at a designated medical facility. During the first 28 days, an employee is required to treat at employer’s dedicated medical facility. If you need the name of a designated medical facility, call Work Connections. For serious incidents, please call 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.