Travelers Insurance Info Sheet - Local

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Enter all information below for Travelers Insurance Claim.

• Full name:

• Position/Craft:

• DOB:

• Address:

• Phone #:

• Social Security #:

• Salary:

• Hire date:

• Email:

• Date and time of injury:

  Date

• Date and time injury was reported:

  Date

• Nature of injury:

• Name of hospital/care provider:

• Phone # of care provider:

• Doctor seen:

• Address of doctor:

• Fax #:

• Supervisors name:

• Supervisor #: