Try our new and improved web form for submitting claims!
- You will receive an e-mail confirmation with your event number and a copy of the claim document for better tracking.
- Simple, easy-to-use web form for quick, online reporting of all claim types.
- The ability to upload supporting claim documentation when submitting a claim.
- Please use Internet Explorer to access the form.
How to complete and submit forms to Work Connections
This form should be completed by the supervisor for ALL work-related injuries or occupational illnesses. For all non-work-related disabilities, the form may be completed by the supervisor or employee.
The Illness or Injury Report form can be completed and submitted entirely online.
Work Connections staff work with the treating physicians to assist in facilitating medical care for employees. This form authorizes Work Connections to obtain medical documentation and discuss an employee's medical condition and treatment with physicians.
- Employees should complete this form in its entirety via the button above.
- Print the form.
- Sign and date the form.
- Return the signed form to Work Connections via email, fax, or U.S. mail.
University employees requesting reimbursement for mileage associated with medical treatment for work-related injuries or illnesses should complete this form.
The Mileage Reimbursement form can be completed and submitted entirely online.
Download Work Connections forms
These forms are viewable in Adobe Acrobat Reader. Click here to download the reader from the Adobe Web site.