Information

  • Audit Title

  • Employer's FEIN

Employers Name

  • Consolidated Waterproofing Contractors, Inc.

Doing Business As

  • Consolidated Waterproofing Contractors, Inc.

Employer's mailing address

  • 10732 Hanna St., Beltsville, MD 20705

Name of workers' compensation carrier/admin.

Policy/Contract #

  • Self Insured?

Employee Info

  • Employee's full name

  • Social Security #

  • Birthdate

  • Employee's mailing address

  • Employee's e-mail address

  • Male or Female?

  • Married or Single?

  • # Dependents

  • Employee's average weekly wage

  • Job title or occupation

  • Date Hired

  • Time employee began work

  • Date and time of accident

  • Last day employee worked

  • If the employee died as a result of the accident, give the date of death.

  • Did the accident occur on the employer's premises?

  • Address of accident

  • What was the employee doing when the accident occurred?

  • How did the accident occur?

  • What was the injury or illness? List the part of body affected and explain how it was affected.

  • What object or substance, if any, directly harmed the employee?

  • Name and address of physician/health care professional

  • If treatment was given away from the worksite, list the name and address of the place it was given.

  • Was the employee treated in an emergency room?

  • Was the employee hospitalized overnight as an inpatient?

  • Report prepared by/title.

  • 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.