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The University of Texas System (University of Texas System)

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The University of Texas System
Employee’s First Report of Work-Related Injury or Endemic Illness
Employee Information
Injured Employee’s Name: ______________________________________ Male ( ) Female ( ) Date of Birth: ____/ ____/ ________
Home/Cell Phone: (_____) ______________ Work Phone: (_____) ______________ Preferred Language: ____________________
Personal Email Address: _____________________________ Work Email Address: ________________________________________
Home Address: _________________________________________City: _____________________ State: _______ Zip: __________
Married ( ) Single ( ) Widowed ( ) Spouse’s Name: _________________ ( ) NA Number of dependent children? ______________
Employing Institution: _______________________ Job Title: ______________________________ Full Time ( ) / Part Time ( )
Department: _________________________________ State/Country of Hire: _____________ Country of Citizenship: _____________
Incident Information
City/Country/Location where occurrence happened (Please be specific) __________________________________________________
Address/Description of location where occurrence happened (Please be specific)___________________________________________
Date of occurrence: ____________ Time of occurrence: ______ ( ) AM ( ) PM Did you notify your supervisor? ( ) Yes ( ) No
Date Supervisor Notified: ________ Time _______ ( ) AM ( ) PM Name of Supervisor: ___________________________________
Were there any witnesses? ( ) Yes ( ) No Witness Name ____________________________ Phone: (_____) ______________
Did you seek medical treatment for this occurrence? ( ) Yes ( ) No If Yes, List name and address of hospital / physician below:
__________________________________________________________________________________________________________
Were days lost from work due to occurrence(not including injury date)? ( ) Yes ( ) No Have you returned to work*? ) Yes ( ) No
Date Returned to work*: ___/ ___/ _______ Trip Purpose/Work Performed: _______________________________________________
Please mark the areas of the body picture below that reflect where you
were injured and check the appropriate boxes to the left.
( ) Back Front View Back View
( ) Head
( ) Face Right Left Left Right
( ) Neck
( ) Shoulder
( ) Arm
( ) Wrist
( ) Hand
( ) Finger(s)
( ) Chest
( ) Abdomen
( ) Ribs
( ) Hips
( ) Buttocks
( ) Thigh
( ) Knee
( ) Leg
( ) Ankle
( ) Foot
( ) Other
The above statement is true and accurate to the best of my knowledge. I confirm that the occurrence described above happened while I was
performing my essential job duties that were assigned to me by The University of Texas System Institution and my employing department.
______________________________________________________ ____________________________ ____________
Injured Employee’s Signature Date Extension
______________________________________________________ ____________________________ ____________
Supervisor’s Signature Date Extension
Please email the completed First Report of Injury to UT System @ bholman@utsystem.edu.
Claims will be sent to Chubb @ ChubbClaimsFirstNotice@chubb.com
Note: Injured employees may be asked to provide Chubb with a passport or driver’s license, proof of
employment and related medical documentation/bills
Describe in detail the nature of your injury or endemic illness
and how it happened (if more space needed, write on back of
sheet)
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
*Return to work could include duties at UT institution as well as those assigned while abroad.
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The University of Texas System (University of Texas System)

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Completed 2 August 2020

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