Injury/Accident Report

• Document No.

• Conducted on

  Date

• Prepared by

• Location
  Address

WORKER'S COMPENSATION LOSS

YOUR INFORMATION

• Your name

• Western Fireproofing of Kansas, Inc. (title)

• Your phone number

INCIDENT INFORMATION

• When did the incident happen?

  Date

• When was the employer notified of the incident?

  Date

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

  YES

  NO

• Job Name

• Job Number

• Location of the Incident
  Address

• Did the incident occur at the Corporate Office or the Warehouse?

  Corporate Office

  Warehouse

• Is this a fatality?

  YES

  NO

• Were the conditions unsafe?

  YES

  NO

• Explain the conditions

• Picture of unsafe conditions

  Media

• Were unsafe acts practiced that led to the injury?

  YES

  NO

• Explain unsafe actions

• Picture of unsafe actions

  Media

• Were there any witnesses?

  YES

  NO

• Witnesses

Witness

• Witness' name

• Witness' phone number

• Witness' e-mail address

• Witness' description of the incident

INJURED EMPLOYEE INFORMATION

• Injured Person's Name

• Supervisor's Name

• Was medical treatment sought?

  YES

  NO
• Initial Treatment Location
  Address

• Did the employee miss work?

  YES

  NO

• When did the employee start missing work?

  Date

• When did the employee return to work?

  Date

• Was corrective action taken?

  YES

  NO

• Explain the corrective action taken

• Additional Remarks

INCIDENT DOCUMENTS & PHOTOS

• Please attach photos of any claim documents related to the the incident that should be considered for this claim.

  Media