Case Submission Form

Step 1

Select Case Type

Step 2

Complete Form

Step 3

Review Form

Step 4

Submit Form & Receive Confirmation Number

The following fields require your attention

What type of case are you reporting?

Some forms may require documentation. Submitting any documentation at this point will help to expedite the process. If you've already submitted a claim through RL at Michigan Medicine, you will need to duplicate that information on this form.

Work Related Illness/Injury

In general, injuries and illnesses which result from events or exposures on the employer's premises are presumed to be work related.

Personal Medical Condition

A personal medical condition is a medical condition that causes or prevents you from working.

Contract Worker

Claim for injuries sustained by employees of contractors working on projects on behalf of the University of Michigan.

FMLA

Report of need for personal leave to care for a family member with serious health condition, military service or other personal leave.

Gender Reassignment

Claim for an individual who is transitioning their gender.

Info Tech (IT) Security

Losses associated with IT security issues. Examples include cyber-attacks, hacking, phishing, HIPAA violations, etc.

Loss Report for Non-Employee Event

Claim for losses associated with an injury or property damage to non-employees. Non-employee students who sustain an injury or property damage should complete this form as well.

Pregnancy

Claim for an employee who is experiencing a pregnancy complication or work in a grant funded position.

Property/Theft Loss

Claim for damage or losses of University of Michigan property. Examples include weather related damage (tornadoes, flood, etc.), accidents, or dishonesty.

Vehicle Accident

Claim for personal injuries or property damage involving University of Michigan owned or leased vehicles.