Office of Risk Management

Forms

All forms require Microsoft Excel 2003 or later or Adobe Reader.

 

Risk Accounting

Comprehensive Property Protection Plan (CPPP)

• First Report of Loss

Unemployment Compensation Insurance Program (UCI)

• UCI Insurance Program Summary
• UCI Reimbursement Procedures
• Appendix A - UCI Benefits Statement
• Appendix B - Fund Source Statement
• Appendix C - UCI C-58R Worksheet
• Appendix D - UCI USAS Worksheet
• Appendix E - UCI Journal Entry

Unemployment Compensation Insurance Procedures (UCI)

• UCI Assessment Procedures
• Appendix A - UCI Calculation Report
• Appendix B - UCI Fund Transfer Report
• Appendix C - WCI/UCI Monthly Premiums Worksheet
• Appendix D - WCI/UCI Premium Due Dates
• Appendix E - UCI Journal Entry
• UCI Rates FY 2007
• UCI Rates FY 2008

Risk Control & Insurance

• First Report of Loss (Loss greater than $25,000)
• Potential Claim Incident Report Form

Risk Control

• DSL Work Area Inspection Checklist
• Fire System Shutdown Form

Risk Finance

• Automobile Insurance Coverage for Officers and Employees
• Property and Casualty Insurance and Surety Bonds

Workers' Compensation Insurance

International Claims- General Information

• International Travel Claims Reporting Guide

Employer Information

• Employer's First Report of Accident/Occupational Disease
• Employer's Statement of Wage Earnings
• Notice to Employees (English)
• Aviso a los Trabajadores (Español)

Foreign General Liability

• General Liability Notice of Occurrence/Claims

Foreign Automobile Claims

• Foreign Automobile Claims- Automobile Liability Loss Notice

Defense Base Act Claims

• Employer's First Report of Accident/Occupational Disease- United States Department of Labor (Use this form to report injuries for U.S. federal and military contracts)
• Employer's Statement of Wage Earnings
• Employer's Supplementary Report of Accident or Occupational Disease

Please contact Rob Fields, Coordinator of Workers' Compensation Insurance Programs at 512.499-4645 to report international injuries or Tracy Seiler, Manager of Risk Finance at 512. 499.4401 to report other international claims.