Title Page

  • Store number
  • Conducted on

  • Prepared by

Untitled Page

  • Date of accident

  • Name of employee

  • Phone number

  • Was this a vehicle accident

  • Name of insurance company and policy #

  • Was the Accident fatal

  • Where the police called

  • Police report number

  • Details of Accident (be as detailed as possible)

  • Does the employee need to go to the doctore

  • Any other relevant information?

  • Manager notes/comments

  • Employee signature

  • Manager signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.