Employers Efroi Worksheet Page 2

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Accident Information
*Where did injury/illness happen (PLEASE NOTE COMPLETE ADDRESS & ZIP)
___________________________________________________________________________________
*What county did the accident occur in? _________________________________________________
*Is the accident location the same as the policy location?
Yes____ No____
*Was this the location where the employee normally worked? Yes____ No____
*If not what was he doing there? _____________________
*Employees Supervisor’s First Name____________________
*Employees Supervisors Last Name _____________________
*Did Supervisor see injury Happen? Yes____ No____ Unknown____
*Did anyone else see the injury happen? Yes____ No____ Unknown____
*If yes give names and contact information: _________________________________________
*What was the employee doing when he/she was injured or became ill?________________________
___________________________________________________________________________________
*How did the injury/illness occur_________________________________________________________
____________________________________________________________________________________
Body part
*What part of body was injured? _________________________________________________________
*Cause of Injury _______________________________________________________________________
____________________________________________________________________________________
*To your knowledge did the employee have another work related injury to the same body part or a
similar illness when working for you?
Yes____ No____
*Did the injury/illness result in the employee’s death? Yes____ No ____ Unknown____
*Was an object involved in the injury/illness? Yes____ No ____
*If yes what object was involved? ____________________________
*Was the injury the result of the use or operation of a licensed motor vehicle?
Yes ____ No ____

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