Workers’ Compensation Injury Reporting Form
In an emergency, immediately call (502) 597-6878 to report the accident and request ambulance services.
Accidents must be reported as soon as possible to Devon Peterika at (502) 597-6134. Always report accidents in a timely manner. Waiting more than 48 hours after the accident may result in the insurance carrier delaying payment, investigating the legitimacy of the claim for possible fraud, or rejecting the claim. The completed form should be submitted to the Office of Human Resources via fax at (502) 597-6450 or by email to firstname.lastname@example.org. The University’s current insurer for work-related injuries is the Kentucky Employers Mutual Insurance Company (KEMI).