Accident Investigation Forms
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4Accident Investigation FORMS
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How to use
Accident investigation forms/statements should be filled out by the
injured employee, supervisor and any witness to the accident.
these
Train your supervisors to conduct the preliminary investigation as soon as possible.
important
IMPORTANT - Care must be taken to assure the investigation is fact finding, not
I
fault finding. Obtaining signed statements as soon as possible following an accident
TOOLS
ensures that you, the employer, have an accurate account of how the injury occurred.
These completed statements are important in helping to correct hazards and prevent
the accident from recurring. They also help to spot possible third-party liability as
Includes:
well as possible fraudulent claims.
After I have these forms completed, what do I do with them?
Employee's Report
of Injury Form
Please send the completed forms to your Claims Adjuster and keep a copy for your
Accident Witness
files. These completed forms can provide valuable information in a claims investi-
Statement Form
gation of an injury and for developing the defense in the event of a workers’ comp
Supervisor's Accident
hearing.
Investigation Form
What if my injured employee is physically unable to fill out the
Employee’s Report of Injury?
Use common sense and good judgement. If the injury is severe, remember, your em-
ployee’s health and care are first and foremost. If possible, have the form filled out at
a later, more appropriate time when the employee is physically able to document the
accident.
What if my employee refuses to fill out or sign an Employee’s Report of
Forms may be copied
Injury?
as needed.
Of course, you cannot make an employee fill out the document. You can, however,
Forms are also
stress the importance of getting his or her account of the accident to set the record
available for printing
straight and to help prevent the accident from happening again. Also, still obtain the
in pdf format online at
supervisor's report as well as any witness statements.
Need Help?
What if my Employee has retained an attorney? Can I still ask the
If you would like
injured employee to fill out an Employee’s Report of Injury?
assistance in setting up
Yes. You, the employer, as part of your company’s accident management plan, can
supervisory training
still ask the employee to fill out the report form.
on how to use these
forms, please contact
your Chesapeake Claims
Adjuster or Safety
Management Consultant
at 1-800-264-4943.
Chesapeake Employers' Insurance Company • 8722 Loch Raven Boulevard, Towson, MD 21286-2235 •
10/2013
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