Title Page
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Conducted on
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Prepared by
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Location
Claim Report Form
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Please complete this form and return it to the project safety manager no longer than 24 hour after the incident.
ACCOUNT INFORMATION
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PROJECT NAME: Interstate 5 North Coast Corridor Project
Solana Beach, CA; Oceanside, CA
Contractor Name: Flatiron / Skanska / Stacy & Witbeck JV
CLAIM INFORMATION
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Claim Type
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Please Specify:
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Date and Time of Injury:
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Weather Conditions:
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Is this claim work related?
EMPLOYEE INFORMATION
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Employee's Name:
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Date of Birth:
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Employee ID
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Home Street Address:
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City:
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State:
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State:
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Zip Code:
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Phone Number:
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Date of Hire:
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Occupation:
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Supervisor:
- Roland Sarimento (619) 719-7993
- Jim Baxter (760) 600-1543
- Barney Stenlake (951) 830-0324
- Mike Strachota (760) 497-4505
- Luis Ruiz (909) 721-9775
- Other
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Name:
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Phone Number:
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Select Gender:
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Marital Status
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Number of Dependents
EMPLOYER INFORMATION
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Employer Name:
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City/State/Zip:
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Employer Name:
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Street Address:
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Contact Name and Title:
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Phone Number:
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Employer FED ID:
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Employer SIC:
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Policy No:
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Nature of Business:
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Address: 1770 La Costa Meadows Drive, San Marco, CA 92078
Contact Name & Title: Kamryn Miller - Claims manager
Contact Phone Number: 760-533-7155
Employer FED ID: 47-1109930
Employer SIC: N/A
Policy No: WXD7445800
Nature of Business: Construction
ACCIDENT INFORMATION
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Type of Injury
- Abrasion
- Allergy
- Burn
- Contusion
- Crush
- Fracture
- Insect Bite
- Laceration
- Pinch
- Puncture
- Sprain/Strain
- Other
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Please Specify:
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Body Part
- Ankle
- Abdomen
- Arm(s)
- Back
- Elbow(s)
- Eye(s)
- Face
- Finger
- Foot
- Hand
- Head
- Hip
- Knee(s)
- Leg(s)
- Neck
- Shoulder
- Toe(s)
- Wrist(s)
- Other
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Please Specify:
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Type of Work Being Performed at the Time of Incident:
- Administration
- Paving
- Structures
- Roadway
- Yard Work
- Utility
- Other
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Please Specify:
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Cause of Injury
- Caught Between
- Fall
- Improper Use
- Lifting
- Material Handling
- Slip/Trip
- Falling Object
- Struck by Equip
- Use of Equip
- Use of Tools
- Other
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Please Specify:
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Did a SAFETY VIOLATION contribute to this accident?
NARRATIVE OF INCIDENT
MEDICAL INFORMATION
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Initial Medical Treatment:
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Hospital (Name, Address, Phone, Fax):
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Clinic/Doctor (Name, Address, Phone, Fax, Specialty):
ADDITIONAL COMMENTS & INFORMATION
SIGNATURES:
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SUPERINTENDENT:
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Phone Number:
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REPORT PREPARED BY:
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Phone Number:
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PROJECT MANAGER:
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Phone Number:
EMPLOYEE STATEMENT:
Signatures
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SUPERINTENDENT:
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Phone Number:
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EMPLOYEE:
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Phone Number:
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PROJECT MANAGER:
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Phone Number:
WITNESS INFORMATION STATEMENT
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Witness
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Witness Name:
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Witness Phone Number:
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Witness Statement
Signatures
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SUPERINTENDENT:
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Phone Number:
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WITNESS:
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Phone Number:
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PROJECT MANAGER:
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Phone Number:
