Start a Worker's Compensation Claim

Instructions for successful submission:

  • Please complete this form as fully as possible.
  • Do not use dollar signs or commas in dollar amount fields. Decimals are okay.
  • Example: 9.52 (not $9.52) or 25800 (not 25,800).
  • If you are unsure what to enter in a field, or the field does not apply, leave it blank.
  • Do not put zeros or “N/A” in date fields.
  • If the field is required and does not apply enter “NONE”

If you have any questions, please call our office at: 435-652-7520.

Worker's Compensation Form

Worker's Compensation Form

Your Relationship to Dixie State University

First we need to determine if you're eligible for Worker's Compensation, or if you should fill out the Incident/Injury Report for guests instead.

  1. Personal Information

  2. Wage

  3. Incident Details

  4. Treatment

  5. Other Information

Students and Visitors should complete the Incident/Injury Report (click here)

Your Information

Home Address
Number of dependents
If employee, enter your job title. If you're a student or visitor, enter "Student" or "Visitor" respectively.