Start a Worker’s Compensation Claim

ACCIDENT PROCEDURES for Employees

Complete a WORKERS COMPENSATION CLAIM FORM and notify the UT HR Office within at least 24 hours of the injury so we may gather and process the injury claim with WCF.

If medical treatment is necessary:

Go to the St. George WorkMed **NEW LOCATION** 577 S River Rd, St. George, UT 84790 (inside Intermountain Health InstaCare building). Their operating hours are Monday – Friday, 8 am – 5 pm. No appointment is necessary.
If after WorkMed hours, visit the River Road InstaCare at 577 River Road In St. George (Near St. George Regional Medical Center) or any other InstaCare location.

Inform the WorkMed or InstaCare staff that you are an employee of Utah Tech University and that your injury occurred while at work. After your visit, please submit any injury-related documents to Human Resources.

** Special Note: Workers Compensation may deny the claim or the employee may be liable for part of the initial treatment costs, if protocol is not followed. Also, the Emergency Room should only be used if the injury is life-threatening or the injury occurred outside of WorkMed and InstaCare office hours.**

LIFE THREATENING EMERGENCIES

Call 911 immediately if the injuries are life threatening. For emergencies, contact the University Police at 911 and for non-emergency call dispatch at (435)627-4300. (Security – Lost & Found, Lock-outs, Jumpstarts, etc., call (435) 236-4000)

Instructions for successful submission:

Please complete this form as fully as possible.
Do not use dollar signs or commas in dollar amount fields. Decimals are okay.
Example: 9.52 (not $9.52) or 25800 (not 25,800).
If you are unsure what to enter in a field, or the field does not apply, leave it blank.
Do not put zeros or “N/A” in date fields.
If the field is required and does not apply enter “NONE”.

If you have any questions, please call the Human Resources office at: 435-652-7520.

Workers Compensation - New

Personal Information
Wage
Incident Details
Treatment
Other Information

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Your Relationship to Utah Tech University

First, we need to determine if you're eligible for Worker's Compensation, or if you should fill out the Incident/Injury Report for guests instead.

Are you a:

Employee (Faculty, Staff, Student Worker)

Student

Visitors (Vendors/Contractors)

Students and Visitors should complete the

Incident/Injury Report (click here)

Personal Information

Last Name

First Name

Middle Name

Digital ID

Home Address

City

State/Province

Zip/Postal

Work Phone

Cell Phone

Email Address

Date of Birth

Marital Status

Gender

Dependents

Number of dependents

Job Title

If employee, enter your job title. If you're a student or visitor, enter "Student" or "Visitor" respectively.

Department / Location

Date Hired

Employment Status Employment Status

Student Status

Preferred Language:

If you are human, leave this field blank.

NOTIFICATION OF AN ON CAMPUS ACCIDENT/INCIDENT FOR STUDENTS, VISITORS, VENDORS, and CONTRACTORS

Any risky, unsafe act or condition, lack of organization preparedness or training, management deficiencies or policy infractions that potentially or does result in injury, property damaged, and/or harm to the University or its stakeholder need to be reported and documented using this Incident/Injury Report as soon as possible. Fill out all blocks. Be as specific and detailed including drawings, photos, additional narratives or any other pertinent information.

Students, Visitors, and Vendors/Contractors please complete an Injury Report (Students/Visitors) if there was an incident/injured on campus.

QUESTIONS? Contact Event Service & Risk Management at 435-652-7855.