Title Page
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Please input the basic details of the incident on this page on the day of the incident.
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Prepared by
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Conducted on
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Location
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Company Working For
- American Tower
- SBA Communications
- Harmoni
- Motorola Solutions
- Boost Mobile
- Nokia
- Crown Castle
- One Way Communications
- Verizon Wireless
- T-Mobil
- T-Mobil Maintenance
- Horvath
- Industrial Tower
- Pierson Wireless
- Hemphill
- Tower North
- Tilman Infrastructure
- Vertical Bridge
- Pyramid Network Services
- Smartlink Group
- Other
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Division
- Civil (Ground)
- Build (Tower)
- Maintenance (Tower)
- TIA (Tower)
- Electrical (Ground)
- DAS (Ground)
- MODs (Tower)
- Other
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Job Number
Employee/Supervision Information
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Employee Involved/Employee Number
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Employee Job Classification
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Employee Phone Number
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Supervisor/Foreman Name/Employee Number
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Supervisor/ Foreman Phone Number
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General Foreman Name/Employee Number
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General Foreman Phone Number
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Division Manager Name/Employee Number
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Division Manager Phone Number
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Division Manager email address
Incident Type
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Types of Incidents:
Worker's Compensation
An incident involving an employee who was injured on the job
General Liability
An incident involving bodily injury or property damage to a 3rd party allegedly from work performed by your Company
Company Property Damage
An incident involving damage to property owned by your Company
Automobile Property Damage
An incident involving a motor vehicle resulting in injury and/or damage to another person or object -
Reporter - Name
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Reporter - Job Classification
- Safety
- Employee
- Office
- Project Manager
- Foreman
- Human Resources
- Fleet Manager
- Warehouse
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Reporter - Phone Number
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Reporter - Email
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Is this claim questionable?
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Please explain:
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Type of Incident Being Reported (Multiple selections are possible if applicable)
- Worker's Compensation - WC
- General Liability - GL
- Company Property Damage/Loss - CP
- Automobile Property Damage - AUTO
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Injury Date and Time
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Time Work Began (use military time i.e. 7:00 AM is 0700)
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Who was the Injury reported to: (Name and Phone Number)
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When was the injury reported? (Date and Time)
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Injured Employee's Name/Employee Number
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Injured Employee's Phone Number (Area Code-XXX-XXXX)
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Injured Employee's Home Address (Street, City, State, Zip Code)
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Injured Employee's Date of Birth (Month/Day/Year)
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Injured Employee's Gender
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Injured Employee's Marital Status
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Injured Employee's State of Hire
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- Florida
- Georgia
- Hawai'i
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
- Other Foreign County
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List Foreign County
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Injured Employee's Work State
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- Florida
- Georgia
- Hawai'i
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
- Other Foreign County
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Injured Employee's Employment Status
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Injured Employee's Number of Dependents
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Injured Employee's Number of Hours paid on Date of Injury
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Injured Employee's Number of Days Worked per Week
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Injured Employee's Number of Hours per Day Worked
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Accident Description (detailed)
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Specific Job Being Done at Time of Accident (i.e. - Hooking up trailer, changing cable, etc.)
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Type/Cause of Injury - Select All That Apply
- Burn or Scald- Heat or Cold Exposure)
- Caught In, Under or Between
- Cut, Laceration, Puncture, Scrape
- Motor Vehicle
- Rubbed or Abraded by
- Strain or Sprain
- Striking Against or Stepping On
- Struck By
- Misc. Other
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Detailed Type/Cause of Injury - Select All That Apply
- Abnormal Air Pressure
- Absorption, Ingestion or Inhalation
- Accident Between Own Units
- Accident on Premises
- Acid/Fuel/Oil Spill
- Air Conditioning Liability
- All Marine Perils including Sinking
- Allergic Reaction
- Animal Collision
- Animal or Insect
- Assault and Battery
- Backing or Rolling Back
- Boiler and Machinery Liability
- Breakage
- Broken Glass
- Burglary/ Robbery/ Hijacking
- Burn/Exposure Abnormal Air Pressure
- Burn/Exposure Chemicals
- Burn/Exposure Cold Object
- Burn Exposure Dust/Gas/Fumes
- Burn Exposure Electrical Contact
- Burn Exposure Extreme Temperature
- Burn/Exposure Fire/Flame
- Burn/Exposure Hot Object
- Burn Exposure Steam/Fluid
- Burn/Exposure Heat/Cold Radiation
- Cargo Shift
- Caught in Door
- Caught in Between Collapsing
- Caught in Between Machinery
- Caught in Between Object Handled
- Chemicals
- Claimant Rear-Ended Other vehicle
- Cold Objects or Substances
- Collapse
- Collided with Fixed Object
- Collided with Pedestrian
- Collision Multiple Vehicles
- Collision Single Vehicle
- Collision Head-on
- Collision Rear Ended
- Collision Side-swiped
- Collision with Animal
- Collision with Fixed Object
- Collision with Motorcycle
- Collision with Other Vehicle
- Container Failure
- Continual Noise
- Crash Airplane
- Crash Railway
- Crash Water Vehicle
- Curved Road
- Cut/Puncture/Scrape- Glass
- Cut/Puncture/Scrape- Hand Tool
- Cut/Puncture/Scrape- Object lifted/handled
- Cut/Puncture/Scrape- Power Tool
- Debris
- Defective Equipment
- Design Defect
- Dirt, Stone, Debris
- Driving Under the Influence
- Dust, Gasses, Fumes or Vapors
- Earthquake
- Electrical Current
- Elevator/Escalator
- Employment Practices
- Equipment
- Exhaustion/Sleep
- Explosion
- Exterior Grade/Floor/Glass Liability
- Exterior Signs Liability
- Fall/Slip Different Level
- Fall/Slip Into Opening
- Fall/Slip Ladder/Scaffolding
- Fall Slip Liquid/Grease
- Fall/Slip Ice/Snow
- Fall/Slip Same Level
- Fall/Slip Stairs
- Falling Object(s)
- Fire
- Flood/Water Damage
- Following Too Closely
- Foreign Matter (body) in Eye(s)
- Freezing
- Gas Lines
- Glass Breakage
- Gunshot
- Hand Tool or Machine in Use
- Hand Tool, Utensil; Not Powered
- Handling or Throwing
- Hill
- Hit and Run
- Hit Parked Vehicle
- Holding or Carrying
- Housekeeping
- Ill From Eating (Food Poisoning)
- Improper Parking/ Pulling from Parked Position
- Inclement Weather
- Irritant/Chemical/Electrical
- Jumping or Leaping
- Landslide
- Lifting or Lowering
- Lightning
- Loading/Unloading
- Lost Control
- Machinery
- Mechanical Failure
- Motor Vehicle
- Moving Part of Machine
- Natural Disaster
- No Contact Accident
- Non-Collision
- Not Applicable
- Object being Handled
- Parking Lot
- Plate Glass
- Power Door
- Powered Hand Tool
- Public Transportation
- Pushing or Pulling
- Radiation
- Reaching
- Repetitive Motion
- Rollover/Overturned
- Sharp Object
- Sidewalk/Street
- Slip/Trip/Did Not Fall
- Smoke Damage
- Speed/Too Fast
- Spill
- Steam/Hot Fluids
- Stepping on Sharp Object
- Strain/injury by Carrying
- Strain/injury by Continual Noise
- Strain/injury by Jumping
- Strain/injury by Lifting
- Strain/injury by Pushing/Pulling
- Strain/injury by Reaching
- Strain/injury by Repetitive Motion
- Strain/injury by Twisting
- Strain/injury by Using Tool
- Struck By Co-Worker
- Struck By Falling Object
- Struck By Hand Tool
- Struck By Machinery
- Struck By Motor Vehicle
- Struck By Moving Part
- Struck By Object Handled by Others
- Struck By Object Handled/Lifted
- Struck While Parked
- Temperature Extremes
- Tornado
- Towing
- Twisting and Turning
- Uneven Surface
- Unknown
- Vandalism
- Vehicle/Mobile Equipment
- Water Damage
- Welding Operatioon
- Wind and Hail
- OTHER
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Nature of Injury - Select All That Apply
- Amputation
- Asphyxiation
- Burn
- Cancer
- Carpel Tunnel Syndrome
- Concussion
- Contagious Disease
- Contusion
- Crushing
- Dermatitis
- Dislocation
- Dust Inhalation
- Electric Shock
- Foreign Body
- Fracture
- Freezing
- Hearing Loss
- Heat Exhaustion
- Heat Stroke
- Hernia
- Infection
- Inflammation
- Laceration
- Mental Disorder
- Multiple Injuries including Physical and Psychological
- Multiple Injuries, Physical Only
- Myocardial Infarction (Heart Attack)
- No Physical Injury
- Poisoning
- Puncture
- Radition
- Respiratory Disorder (gasses, fumes, etc.)
- Rupture
- Sprain
- Strain
- Syncope (Dizzy/faint due to Blood Flow)
- Vision Loss
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Body Part(s) Affected - Select All That Apply
- Abdomen including Groin- L
- Abdomen including Groin- R
- Ankle- L
- Ankle- R
- Arm- Lower- L
- Arm- Lower- R
- Arm- Upper- L
- Arm- Upper- R
- Back- Lumbar- Lower
- Back- Lumbar- Upper
- Back- Thoracic- Middle
- Back- Upper- cervical/Neck
- Buttocks
- Chest
- Ear- L
- Ear- R
- Elbow- L
- Elbow-R
- Eye- L
- Eye- R
- Facial Bones
- Facial Soft Tissue
- Finger- Index- L
- Finger- Index- R
- Finger- Middle- L
- Finger- Middle- R
- Finger- Pinky- L
- Finger- Pinky- R
- Finger- Ring- L
- Finger- Ring- R
- Finger- Thumb- L
- Finger- Thumb- R
- Foot- L
- Foot- R
- Foot- Toe(s)- L
- Foot- Toe(s)- R
- Hand- L
- Hand- R
- Head Injury- Multiple
- Hip- L
- Hip- R
- Internal Organs
- Leg- Lower/Calf- L
- Leg- Lower/Calf- R
- Leg- Upper/Thigh- L
- Leg- Upper/Thigh- R
- Lung- L
- Lung- R
- Mouth
- Multiple Body Parts
- Neck- Soft Tissue
- No Physical Injury
- Pelvis- Back
- Pelvis- front (including scrotum and coccyx)
- Shoulder- L
- Shoulder- R
- Skull
- Teeth- Lower Back- L
- Teeth- Lower Front- L
- Teeth- Upper Back-R
- Teeth- Upper Front- R
- Trachea
- Trunk/Disc
- Whole Body
- Wrist- L
- Wrist- R
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Add photos if possible
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Initial treatment
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Type of Treatment
- Emergency Room (Going Home after Initial Treatment)
- Future Major medical Treatment/Lost Times Anticipated
- Hospitalization (Not going home after treatment)
- Minor- First Aid
- No Medical Treatment
- Physician/Clinic Treatment First Aid
- Physician/Clinic Treatment OSHA Recordable
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Name and Address of ER
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Name and Address of Hospital
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Name and Address of Clinic
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Name and Address of Clinic
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Was Employee Drug and Alcohol tested?
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Why?
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Did Injury Result in Death?
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Employee Death Date
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Description of Exact Location of Accident/Illness (Tower inside jobsite)
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Accident Site Address (Address, City, State, Zip, County)
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Were safeguards used?
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Please explain why safeguards were not used:
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Description of equipment used during the accident:
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Describe the activity and work process engaged in during the accident:
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Did employee do or fail to do that caused or contributed to the accident?
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Explain failure that lead to accident:
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What may have caused or contributed to above unsafe CONDITION(s)- Select all that apply
- Caused by employee
- Caused by Other employee
- Defective via misuse/misuse
- Defective via normal use
- Exposure to corrosion
- Exposure to heat/cold
- Faulty construction
- Faulty design/guards
- Housekeeping failure
- Illumination defect
- Poor preventative maintenance
- Safety inspection failure
- Unable to determine
- Ventilation defect
- None
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What may have caused or contributed to above unsafe ACTION(s)? - Select All That Apply
- Causes by Other sources than listed
- Defective hearing
- Defective vision
- Fatigue influenced action
- Ignored known hazard
- Illness influenced action
- Low level job skill
- Other physical condition
- Tried to avoid discomfort
- Tried to avoid effort
- Tried to save time
- Unable to determine
- Unaware of hazrd
- Under the influence
- None
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Employee who investigated the incident (Name/Phone Number/Title)
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Was corrective action taken?
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Person responsible for corrective action (Name/Phone Number/Title)
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Is employee expected to miss work from injury?
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Date Loss time began
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Person responsible for monitoring lost-time activity?
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Is the injury the result of a pre-existing condition?
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What is the pre-existing condition?
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Type of Party Injured or Damaged
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Injured Party name
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Injured Party phone number
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Injured party address (street, city, state, zip, county)
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Business Name
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Business Phone Number
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Business address (street, city, state, zip, county)
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Business owner contact name
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Date of Incident
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Accident premises indicator
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Did accident occur at a different location than the business owner address?
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Accident address (street, city, state, zip, county)
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Describe in detail the accident:
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Was the property owner contacted?
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Name and Phone number of the property owner
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Type of property that is damaged:
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Estimate of damage (rough initial estimate based on what you know is damaged)
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Was a utility or line damaged?
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Was mechanical equipment being used at the time of the incident?
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Type of mechanical equipment being used:
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Was the equipment rented?
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Where was equipment rented from?
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Company Equipment Number
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Was there damage to the equipment?
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Describe damage:
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Utility that was damaged (mark all that apply)
- Gas or Oil
- Electric
- Communications (Fiber or Coax)
- Water
- Sewer
- Reclaimed Water
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Miss utility/8-1-1/One Call Contacted?
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Locate ticket information (locate number, date and time called in, name of individual who called in locate request)
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Why was locates not called in for this project?
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Was the line/conduit properly marked?
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Please explain:
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Was the utility owner or representative contacted?
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Name, phone number and company name of representative contacted:
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Did representative respond to the jobsite?
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What could have prevented the damage?
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Company Loss Location (address, city, state, zip and county)
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Company loss property description (i.e. vehicle, tools, etc. A detailed question about loss will be asked further down)
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Was company loss due to employee use/misuse?
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What actions lead to property loss?
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Was company loss due to theft?
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Was police report filed for company loss?
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Name of Police department and report number if available
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Why was a police report not completed for property loss?
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Company items loss/damaged and estimated values (add detailed information i.e. Milwaukee grinder $299.00, Kobalt tool set $199.00, etc.)
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Total loss value in dollars ($1500.00)
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Accident detailed description:
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Authorities contacted?
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- Police
- Fire
- EMS
- OSHA
- EPA
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Name of Police Department
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Name of Fire Department
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Name of EMS Paramedic Service
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Was this due to a fatality?
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Why was OSHA contacted?
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Was this due to a chemical spill
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Why was the EPA contacted?
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Did the employee receive a citation for the accident?
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Explain why the employee was cited:
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Were Hazardous Materials, other than fuel, spilled from the motor vehicles involved?
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Please explain:
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Road Characteristics
- Straight
- Curved
- Highway
- Intersection
- Level
- Paved Road
- Slight grade
- Unpaved Road
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Road Surface
- Dry
- Icy
- Muddy
- Snowy
- Wet
- Other
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Road Defects
- Defective Shoulders
- Holes, Deep Ruts, Bumps
- Loose Material on Surface
- Snow/Ice/Rain
- No defects
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Traffic Control
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Light
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Weather
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Company vehicle Unit number
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Company Vehicle Type
- Utility Bed Truck
- Pick Up Truck
- Squirt Boom
- Bucket Truck
- Digger Derrick
- Back Yard Machine
- Excavator
- Tractor Trailer
- Car
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Company Vehicle Year, Make and Model
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Company Vehicle VIN
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Description of Damage
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Is the Company Vehicle driveable?
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Was the Company Vehicle Towed?
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If towed, location of the vehicle:
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Remember to take picture of all four sides of the company vehicle(s) involved, all four sides of any other vehicles involved and a full scene photo that captures the traffic flow, weather elements, etc. and attach all photos to Primeline US Claims
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Is the company driver CDL licensed?
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Was company driver wearing their seat belt?
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For all at-fault accidents, company driver must be drug and alcohol tested within two hours of the event
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Name and address of drug and alcohol testing facility
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Was the company driver or any passengers injured?
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If injuries to any company representatives, complete the injury report portion for each employee injured
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Make model and year of other vehicle(s) involved
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Damage to other vehicle(s)
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Driver(s) of other vehicles (Name(s) and Phone numbers)
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Are there apparent injuries of the other vehicles driver(s) or any passengers?
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Please list names (if available) and any apparent injuries. If names are not available, use (Male- vehicle 1 driver- head laceration)
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Were other vehicles involved towed from the scene?
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Were any citations given to the other driver's involved?
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Are there traffic or business cameras installed close to the accident scene that are visible?
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Please list the business name or street location of the traffic or business cameras). This footage could be used if the incident goes to litigation.
Witness Information
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Were there any witnesses to the incident reported?
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Please add the name and phone number of any witnesses involved
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Are the witnesses company employees?
Additional Comments
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Please include any other information not asked during this incident description that is pertinent information to the incident prior to submitting to PrimelineUS claims.
