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Workers Compensation First Report of Accident
Company Name:
Policy Number:
Claim Number:
Employee Name:
Date:
Address:
Gender:
Full Time or Part-time:
Part-time
Full time
Marital Status:
Date of Birth:
Home Phone Number:
Pay Rate:
Occupation/Job Title:
Date of Hire:
Date of Injury:
Time of Injury:
AM/PM
AM
PM
Full Pay for Date of inury:
Yes
No
Describe work employee was performing at time of accident:
Describe where and how accident occurred:
Were there any witnesses who actually saw the accident?
Yes
No
Who?
Witnesses phone #:
Part of body injured:
Was injury related to a previous injury?
Yes
No
Medical Treatment:
First aid on premises
Professional medical treatment
Hospitalization
Employee Work Released For:
Regular duty on
Restricted duty
Off-work, re-check on
Treatment given by:
Address:
Was immediate corrective action taken?
Yes
No
Did you ever notify your immediate supervisor about the problem?
Yes
No
If so, when?
More than once?
Yes
No
Did you ever notify your HR department?
Yes
No
If yes, when?
Additional action taken / comments:
Report by:
Report date:
Reviewed by:
Reviewed date:
