"Basic Accident Report Form - Employers"

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Basic Accident Report
Date of Report:
Report Completed By:
Last Name of Injured
First Name:
Job Title:
Person:
Date of Accident:
Time of Accident:
Location of Accident:
Supervisor’s Name & Job Title:
Name of Witnesses:
Full Description of Injuries:
Description of accident/incident or employee’s account, including sequence of events
preceding the accident:
Basic cause and contributory causes. Explain fully unsafe act, unsafe condition,
personal factor, other:
Recommended Corrective Measures:
Action By:
Names of Inspection Team Participants:
Management Review By:
Date to be Completed By:
®
®
EMPLOYERS
and America's small business insurance specialist
are registered trademarks of Employers Insurance Company of Nevada. Insurance is
offered through Employers Compensation Insurance Company, Employers Insurance Company of Nevada, Employers Preferred Insurance Company, and
Employers Assurance Company. EIG Services, Inc. (in California, dba EIG Insurance Services) is an affiliated agency and adjuster. Not all insurers do
business in all jurisdictions.
CL_PH_0004_US
Rev 07/2016
Basic Accident Report
Date of Report:
Report Completed By:
Last Name of Injured
First Name:
Job Title:
Person:
Date of Accident:
Time of Accident:
Location of Accident:
Supervisor’s Name & Job Title:
Name of Witnesses:
Full Description of Injuries:
Description of accident/incident or employee’s account, including sequence of events
preceding the accident:
Basic cause and contributory causes. Explain fully unsafe act, unsafe condition,
personal factor, other:
Recommended Corrective Measures:
Action By:
Names of Inspection Team Participants:
Management Review By:
Date to be Completed By:
®
®
EMPLOYERS
and America's small business insurance specialist
are registered trademarks of Employers Insurance Company of Nevada. Insurance is
offered through Employers Compensation Insurance Company, Employers Insurance Company of Nevada, Employers Preferred Insurance Company, and
Employers Assurance Company. EIG Services, Inc. (in California, dba EIG Insurance Services) is an affiliated agency and adjuster. Not all insurers do
business in all jurisdictions.
CL_PH_0004_US
Rev 07/2016