WORKERS COMPENSATION
This Workers' Compensation Form is designed to collect essential information regarding any work-related injuries or illnesses. Please provide accurate details about the incident, including the date, time, pictures, and location of the event, along with a description of the injury or illness sustained.
This information is crucial to processing your claim efficiently and ensuring you receive the appropriate benefits and support during your recovery. Your supervisor must complete and sign the forms. You must complete and sign the Panel of Physicians form. Ensure all sections are completed fully and truthfully to avoid any delays in the processing of your claim. Please print (all forms) and submit all completed forms to the EHS&RM department.
NEED TO FILE AN AUTOmobile OR INJURY CLAIM?
Injury damage claims involving the University are routed through the Environmental, Health, Safety and Risk Management Department. This office will collect information in preparation for the defense or pursuit of liability allegations.
All incidents involving motor vehicles must immediately be reported to Norfolk State University Police. NSU University Police will investigate, prepare reports and may issues summons if warranted. Individuals involved in vehicle incidents are expected to fully cooperate with the officer(s) on the scene. Any injuries must be reported to the officer, who can contact emergency medical responders, if required.
Norfolk State University is part of the Commonwealth of Virginia. Various remedies may be available to those seeking to make a claim against the Commonwealth and you may wish to consult a private attorney regarding your situation. In order to protect your legals right, NSU is not authorized to provide instructions or advice about how to pursue a claim.
Pursuant to the Virginia Tort Claims Act, the Division of Risk Management (DRM) administers claims against the Commonwealth. For additional information, you can visit their link on the Department of Treasury's website at ww.trs.virginia.gov.
Department of the Treasury
Division of Risk Management
P.O. Box 1879
Richmond, VA 23218-1879
804-786-3152 (Telephone)
804-371-2442 (Fax)
CERTIFICATES OF INSURANCE
State agencies and institutions required to provide a liability certificate of coverage for their activities may request a Certificate of Coverage via e-mail at rdallmond@nsu.edu or alicemusapatike@nsu.edu. In the event of a claim or lawsuit please forward a copy of the certificate to DRM along with other relevant documents.
Department of the Treasury
Division of Risk Management
P.O. Box 1879
Richmond, VA 23218-1879
804-786-3152 (Telephone)
804-371-2442 (Fax)