Accident Report Form  

Contact Office immediately and return this Form as soon as possible

Injured:
Name:______________________ Date of Birth:________________
Phone:______________________ Work Phone:________________
Address:_______________________________________________
Male:___ Female:___
Describe Injury:__________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

Witnesses:
Name:_____________________________ Phone:_______________
Name:_____________________________ Phone:_______________
Name:_____________________________ Phone:_______________

Employee:
Location of Accident:______________________________________
______________________________________________________
Date and Time of Accident:_________________________________
Description of Accident:____________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

If slip and fall please take pictures of area with disposable camera.

Is  Injured party seeking medical attention?     Yes     No
Is this an employee or customer?                     Emp   Cust

Signature of Injured Party:___________________________________

Signature of Clerk on Duty:__________________________________

Station ___________________________________________________