SU-17B Non-Employee Incident Report

You may download:

A printable version in PDF format.
You will need Adobe's Acrobat Reader. Once downloaded you will need to print the form, fill it out and follow the instructions.

OR

A MS Word version*. This version may be filled out electronically, from within Microsoft Word, then printed.

* Macro protection will need to be turned off to allow the hyperlinks in the document to work.

Either version should be sent to the

Risk Management Department
Mail Code 6207

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.