SU-17 Accident, Incident or Exposure Report
You may download:
A printable version in PDF format.
You will need Adobe's Acrobat Reader. Once downloaded you will need to
print the form, fill it out and follow the instructions.
OR
A MS
Word version*. This version may be filled out electronically, from
within Microsoft Word, then printed.
* Macro protection will need to be turned off to allow the hyperlinks in the document to work.
Either version should be sent to the
Risk Management Department
Mail Code 6207
Any person who makes or causes
to be made any knowingly false or fraudulent material statement
or material representation for the purpose of obtaining or
denying workers' compensation benefits or payments is guilty of a
felony. |
Risk Management, Mail Code 6207, 723-7400
SU-17 (01/03)
|