Date: __________ Employee (Claimant’s) Name: ____________________________ Age: ______ Phone: _____________
Address: _______________________________________________________________________ Description of Occurrence:
___________________________________________________________________________. Injuries: __________________________________ Medical Care? YES NO Ambulance? YES NO Hospital or Doctor: _________________________________ Property Damage? YES NO describe same: _________________________________
.
Is a Product Involved? YES NO Name and Size: _______________________________ Name and Address of Manufacturer: ___________________________________________
.
Did Claimant Slip, Fall, or Trip? ___________ Was Area Inspected? YES NO Foreign Matter or Debris Found on Floor? YES NO Describe: __________________
.
Witnesses: Name: _____________________________________ Phone: ____________ Address: ________________________________________________________
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