& Occupational Health,
MUS Workers' Compensation Program
Injured Employee and Supervisor may complete the form together.
Employee provides all Worker Information. The "next" button automatically emails instructions to the Supervisor.
Supervisor completes requested information, prints the form for the Employee to sign and date, and then hits the "next" button to continue routing.
- send signed and dated form to Mike Panisko, 34D Phyiscal Plant; and,
- call the third party administrator, Intermountain Claims, 866-722-4421, if Employee has or is seeking any medical treatment. (If an emergency, Supervisor can call Mike Panisko at 243-2842 when appropriate.)