Accident Investigation Forms Page 2
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4Employee's
Policyholder:
Report of Injury
Policy #:
(To be completed by the employee only.)
Employee's name: __________________________________________________________ Male__ Female__
Last
First
Middle
Date of birth: ____/____/____
Home telephone # ( ______ ) _________________________________
Marital status: M / D / W / S
Height/Weight: ______" /______ lbs.
__Right- or __left-hand dominant
Home address: ___________________________________________________________________________
City: ______________________________________________ State: ______ Zip Code: _________________
Current job position: __________________________________ How long employed here: _____________
Social Security No.: _______-______-__________ Weekly salary: ________________________________
Location of accident:______________________________________________________________________
Address and location of accident (loading dock, bathroom, etc.)
Date of accident: _________________________________________ Time of accident: __________________
Describe fully how accident occurred (including events that occurred immediately before the accident):
_______________________________________________________________________________________
_______________________________________________________________________________________
Describe bodily injury sustained (be specific about body part(s) affected): ___________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Recommendation on how to prevent this accident from recurring:____________________________________
_______________________________________________________________________________________
Name of supervisor: _________________________________________ Phone #_______________________
Last
First
Name(s) of witness(es): ______________________________________ Phone #_______________________
(Attach witness(es) report(s))
When did you report the accident to your supervisor? ____________________________________________
To whom did you report the injury?_____________________________________________________________
Do you require medical attention? Yes:_______ No:_______ Maybe:__________
Name of your treating physician:________________________________ Phone #______________________
Signature of employee: ________________________________________ Date: ______________________
Chesapeake Employers' Insurance Company • 8722 Loch Raven Boulevard, Towson, MD 21286-2235 •
Form may be copied as needed.
10/2013
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Parent category: Business