NYU Work Related Incident / Injury Form
Please fill out as completely as possible before submitting to the Insurance Department!
This form is to be filled out by Supervisors or
Human Resource Representatives ONLY!
Attention Supervisors:
Notify your Human Resources Representative of all work related incidents and injuries.
insurance_web_site028015.jpg
Employees should not use this form to submit Workers' Compensation claims. You must notify your supervisor immediately of any work related incident, injury or illness.
GENERAL INSTRUCTIONS:
Use the TAB key or MOUSE click to move from field to field.
CAUTION: Using the ENTER key will automatically submit the form.

PLEASE REVIEW YOUR SUBMISSION BEFORE CLICKING "SUBMIT"
If your Browser blocks Active Content, Please click on the Information Bar above & Allow Blocked Content!
insurance_web_site028014.gif
insurance_web_site028013.jpg
New York University
Insurance & Risk Management Department
Home
I
Contact
insurance_web_site028012.gif
insurance_web_site028011.gif
insurance_web_site028010.gif
insurance_web_site028009.gif
insurance_web_site028008.gif
insurance_web_site028007.gif
insurance_web_site028006.gif
insurance_web_site028005.gif
Home Page
Student Personal Property Insurance
Workers' Compensation
Vendor Insurance
Who's Who?
Travel Assistance Services
Property Claims Procedure
Laptop Insurance
I
Location & Hours
insurance_web_site028004.gif
Links
insurance_web_site028003.gif
Student Film Program
insurance_web_site028002.jpg
Click Here To Go To Form
insurance_web_site028001.gif
insurance_web_site028001.gif
insurance_web_site002002.gif
insurance_web_site002002.gif
insurance_web_site002002.gif
nyu_torch2.jpg