Uiuc Public Injury Property Damage Report Form
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1UNIVERSITY OF ILLINOIS
PUBLIC INJURY/PROPERTY DAMAGE REPORT
PLEASE TYPE, OR PRINT CLEARLY USING INK – ALL FIELDS MUST BE COMPLETED TO INITIATE INVESTIGATION PROCESS
WHY ARE YOU MAKING THIS REPORT?
PROPERTY DAMAGE
BODILY INJURY
WHEN DID THIS HAPPEN?
DATE OF INCIDENT ________________________________________________
TIME ___________________________ A.M.
P.M.
WHERE DID THIS HAPPEN?
WHERE EXACTLY DID THIS OCCUR? ____________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PROPERTY OWNER _________________________________________________________________________________
ADDRESS _________________________________________________________________________________________
CITY___________________________________________ STATE ___________________________ ZIP _______________
WHO ARE YOU?
GENERAL PUBLIC STUDENT VISITOR
EMPLOYEE (
)
Complete Workers’ Compensation form
IMPORTANT:
MEDICARE ELIGIBLE
CURRENTLY A MEDICARE BENEFICIARY
Senate Bill 2499 requires you answer affirmatively if you are
or
NAME________________________________________________________ SSN/UIN ____________________________
STREET _______________________________________________________ PHONE (_____)_______________________
CITY ____________________________________________ STATE_______________________ ZIP __________________
DATE OF BIRTH
______________ JOB TITLE ________________________________DEPT ___________________
(required)
(IF APPLICABLE)
(IF APPLICABLE)
WHAT EXACTLY HAPPENED?
DESCRIPTION OF ACCIDENT/DAMAGE/INJURY ____________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
WHO WITNESSED THIS INCIDENT?
(USE REVERSE IF MORE THAN ONE WITNESS)
NAME __________________________________________________________________ PHONE (____)_____________
ADDRESS _________________________________________________________________________________________
CITY___________________________________________ STATE ___________________________ ZIP _______________
WERE POLICE NOTIFIED?
YES
NO
REPORTED BY _________________________________
DEPARTMENT CONTACTED ____________________________________ DATE REPORTED ________________________
PHONE NUMBER/DEPARTMENT LOCATION (IF KNOWN) ___________________________________________________
NAME OF INDIVIDUAL COMPLETING THIS REPORT ______________________________________________________
JOB TITLE ________________________________DEPT ________________ OFFICE PHONE _____________________
(IF APPLICABLE)
(IF APPLICABLE)
(IF APPLICABLE)
SEND ORIGINAL TO: Office of Worker’s Compensation and Claims Management
100 Trade Centre, Suite 103, MC-686, Champaign, IL 61820
(217) 333-1080
Fax (217) 244-5152
workcomp@uillinois.edu
RETAIN A COPY FOR YOUR DEPARTMENTAL OR PERSONAL RECORDS
(Rev. 1/10)
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