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For Businesses
Business Insurance
Employee Benefits
Alternative Risk
Surety Bonds
Industry Focus
For Individuals
Property & Home Insurance
Auto Insurance
Personal Umbrella
Recreational Vehicles
Health & Medicare
Life
Resources
Forms
Privacy Policy
Blog
About
Meet Our Team
Testimonials
Careers
Contact
Request a Quote
Request A Quote
Customer Accident/Incident Report
Date
MM slash DD slash YYYY
Policy Number
Phone Number
Store Name
Address
General Information
Date of Incident
MM slash DD slash YYYY
Exact Time of Accident
Manager On Duty During Accident
Employee Filling Out Report
Did You Witness The Accident
Yes
No
If Not, Who Informed You Of The Accident?
Outside Weather Conditions (All That Apply)
Clear
Cloudy
Raining
Snowing
Windy
Light
Dark
Descriptions of Accident/Incident
Exact Location of Accident/Incident
Name, Address, Phone and/or Website for Manufacturer or Supplier of Product, Equipment, Merchandise. PLEASE SAVE FOR FURTHER INVESTIGATION
Did You Inspect The Location Immediately After The Incident?
Yes
No
Exact Time of Inspection
Number of Photographs Taken
Was The Location Clean?
Yes
No
Was The Location Dry?
Yes
No
Last Time The Area Was Cleaned?
MM slash DD slash YYYY
Who Cleaned?
Describe Lighting Conditions
Injured Person Information
Full Name
Phone Number
Date of Birth
MM slash DD slash YYYY
Address
Name of Employer
Occupation
Work Phone
Type of Footwear Injured Person Was Wearing
Was Injured Person Wearing Glasses
Yes
No
Describe Injury
Describe Medical Care At Scene; Name of Doctor, Hospital or Clinic
Where Taken and How
Name of Injured Person's Companion, If Any
Their Address
Their Phone Number
Witnesses, If Any
Their Name
Their Address
Their Phone Number
Their Name
Their Address
Their Phone Number
Phone
This field is for validation purposes and should be left unchanged.
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