Accident Investigation Forms Page 3
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4Accident Witness
Policyholder:
Statement
Policy #:
(To be completed by accident witness.)
Injured employee's name: ___________________________________________________________________
Last
First
Middle
Name of witness: ___________________________________________________ Phone # __________________
Last
First
Middle
Job title of witness: _________________________________________ How long employed here?_________
Home address of witness: ___________________________________________________________________
City: ______________________________________________ State: ______ Zip Code: _________________
Is witness any relation to the injured employee? ___Yes ___No If yes, what relation? _________________
Location of accident: ______________________________________________________________________
Address/name of building; area (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 witness' supervisor: _________________________________________ Ph #_________________
Last
First
Signature of witness: ________________________________________ 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