Title Page
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Store number
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Conducted on
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Prepared by
Untitled Page
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Date of accident
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Name of employee
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Phone number
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Was this a vehicle accident
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Name of insurance company and policy #
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Was the Accident fatal
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Where the police called
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Police report number
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Details of Accident (be as detailed as possible)
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Does the employee need to go to the doctore
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Any other relevant information?
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Manager notes/comments
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Employee signature
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Manager signature
