"Accident/Injury Report Form"

ADVERTISEMENT
ADVERTISEMENT

Download "Accident/Injury Report Form"

206 times
Rate (4.4 / 5) 9 votes
ACCIDENT / INJURY REPORT
PLACE OF ACCIDENT
Business Name:
Contact Person:
Phone:
Address/Location:
Date of Accident:
Specific Site of Accident:
Time of Day:
Lighting:
Weather:
Condition of Accident Site/Hazards Present:
PERSONS INJURED
Name:
Phone: (H)
DOB:
SSN:
(W)
Address:
Description of Injured Party (height, weight, clothes, shoes, glasses, disabilities, etc.)
Nature and Extent of Injury:
Medical Aid Offered or Rendered:
PROPERTY DAMAGE
Nature and Extent:
Persons Involved:
Address:
Phone:
Date of Incident:
DESCRIPTION OF ACCIDENT
IMPORTANT: NAMES & ADDRESSES OF WITNESS
Name:
Address:
Phone:
Name:
Address::
Phone: __________________
Name:
Address :
Phone: __________________
Person Completing Report:
Date of Report:
Any person who, with the intent to injure, defraud or deceive any insurance company, submits a statement
of claim containing false, incomplete or misleading information my be subject to criminal and/or civil
penalties.
F20-974 Ed.07-02
ACCIDENT / INJURY REPORT
PLACE OF ACCIDENT
Business Name:
Contact Person:
Phone:
Address/Location:
Date of Accident:
Specific Site of Accident:
Time of Day:
Lighting:
Weather:
Condition of Accident Site/Hazards Present:
PERSONS INJURED
Name:
Phone: (H)
DOB:
SSN:
(W)
Address:
Description of Injured Party (height, weight, clothes, shoes, glasses, disabilities, etc.)
Nature and Extent of Injury:
Medical Aid Offered or Rendered:
PROPERTY DAMAGE
Nature and Extent:
Persons Involved:
Address:
Phone:
Date of Incident:
DESCRIPTION OF ACCIDENT
IMPORTANT: NAMES & ADDRESSES OF WITNESS
Name:
Address:
Phone:
Name:
Address::
Phone: __________________
Name:
Address :
Phone: __________________
Person Completing Report:
Date of Report:
Any person who, with the intent to injure, defraud or deceive any insurance company, submits a statement
of claim containing false, incomplete or misleading information my be subject to criminal and/or civil
penalties.
F20-974 Ed.07-02
TAKE IMMEDIATE STEPS TO PREVENT FURTHER ACCIDENTS.
Immediately take photos of area where accident took place or damage occurred.
If incident caused by defective equipment, repair as soon as possible and retain parts.
Report this to the appropriate claims office by fax or phone.
REPORTING INSTRUCTIONS
REPORT ANY AUTO ACCIDENT IMMEDIATELY, WHETHER OR NOT YOU ARE AT FAULT
If no one is injured, and property damage, if any, is moderate, complete this form, giving as complete
information as possible, and mail it to the Federated office servicing the state. If there is any indication of
bodily injury, however slight, or if there is serious property damage, call Federated office using the toll free
number if one is listed, otherwise call collect.
FEDERATED PROPERTY AND CASUALTY CLAIMS OFFICES AND STATES SERVICED BY EACH
AL, GA, MS, SC, TN
IL, WI
IA, MN, ND (Mutual only), SD
FL
D.C., DE, KY, MD,
P.O. Box 467500
P.O. Box 328
P.O. Box 390850
P.O. Box 31716
NC, VA, WV
ATLANTA, GA 31146
OWATONNA, MN 55060
MINNEAPOLIS, MN 55439
TAMPA, FL 33631
P.O. Box K178
Ph: (770) 390-3900
Ph: (507) 455-5200
Ph: (952) 831-4300
Ph: (813) 287-0155
RICHMOND, VA 23288
800-237-8292
Ph: (804) 282-4263
800-241-4945
800-533-0472
800-328-9291
FAX: (770) 390-3910
FAX: (507) 455-8079
FAX: (952) 820-2311
FAX: (813) 287-8381
800-446-3039
FAX: 800-416-0027
FAX: (804) 282-5742
AZ, CO, ID, MT, NV,
AR, KS, MO, NE
CA
CT, IN, ME, MA, MI, NH,
LA, OK, TX
NM, ND (Service Only), OR,
P.O. Box 419444
P.O. Box 3150
NJ, NY, OH, PA, RI, VT
P.O. Box 1548
UT, WA, WY
KANSAS CITY, MO 64141
RANCHO CORDOVA, CA
P.O. Box 50487
HURST, TX 76053
P.O. Box 35910
Ph: (913) 451-1962
Zip: 95741-3150
INDIANAPOLIS, IN 46250
Ph: (817) 581-7111
PHOENIX, AZ 85069
800-445-0109
Ph: (916) 631-0345
Ph: (317) 849-7550
800-633-6040
Ph: (602) 944-5566
FAX: (913) 451-9673
800-423-1842
800-428-4143
FAX: (817) 581-2970
800-527-5999
New Claims Fax: 800-239-3256
FAX: (916) 631-0275
FAX: (317) 845-8841
New Claims Fax: 877-308-4994
FAX: (602) 375-7062
FEDERATED WORKERS’ COMPENSATION CLAIMS OFFICES AND STATES SERVICED BY EACH
IL, IA, MN, SD, WI
AL, FL, GA, MS, SC, TN
CT, IN, ME, MA, MI,
D.C., DE, KY, MD, NC, VA
P.O. Box 390850
P.O. Box 31716
NH, NJ, NY, PA, RI, VT
P.O. Box K178
MINNEAPOLIS, MN 55439
TAMPA, FL 33631
P.O. Box 50487
RICHMOND, VA 23288
Ph: (952) 831-4300
Ph: (813) 287-0155
INDIANAPOLIS, IN 46250
Ph: (804) 282-4263
800-328-9291
800-237-8292
Ph: (317) 849-7550
800-446-3039
FAX: (952) 820-2311
FAX: (813) 287-8381
800-428-4143
FAX: (804) 282-5742
New Reports Fax: 800-270-
New Reports Fax: 888-287-0155
FAX: (317) 845-8841
0032
AZ, CA, CO, ID, MT, NM,
AR, KS, MO, NE
LA, OK, TX
NV, OR, UT, WA, WY
P.O. Box 419444
P.O. Box 1548
P.O. Box 35910
KANSAS CITY, MO 64141
HURST, TX 76053
PHOENIX, AZ 85069
Ph: (913) 451-1962
Ph: (817) 581-7111
Ph: (602) 944-5566
800-445-0109
800-633-6040
800-527-5999
FAX: (913) 451-9673
FAX: (817) 581-2970
FAX: (602) 375-7062
New Reports Fax: 800-239-3256
New Reports Fax: 877-308-4994
F20-974 Ed.07-02
Page of 2