EMPLOYEE INJURY/ACCIDENT FORM
***Managers/Supervisors of KLC will STILL be required to complete the hand written form from our insurance company attached to this task, and submit it to to HR by completing this form***
PERSON SUBMITTING FORM:
Name:
*
First Name
Last Name
Email:
*
example@example.com
Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Store Location:
*
Please Select
Andover
Dennis
Fairhaven
Hudson
Indian Orchard
Milford
North Grafton
Pembroke
Sharon
Uxbridge
Uxbridge Paint
Whitinsville
Berlin, CT
Cheshire, CT
East Hampton, CT
Meriden, CT
Kitchen & Bath
Estimating & EWP
Purchasing
Whitinsville Store Admin
Sutton Admin
Marketing
Accounts Payable
Credit Dept
Human Resources
IT
Service Department
Lumber Sales
Inside Sales
Other
DATE OF REPORT AND INCIDENT:
Today's Date:
*
-
Month
-
Day
Year
Date
Date of Accident/Injury/Near Miss:
*
-
Month
-
Day
Year
Date
EMPLOYEE(S) INJURED/INVOLVED IN ACCIDENT:
Employee Name(s):
*
Was There Damage to Property or Equipment:
*
Please Select
Yes
No
BRIEFLY DESCRIBE THE INJURY/ACCIDENT/NEAR MISS:
Description:
0/250
ATTACH EMPLOYEE ACCIDENT FORM HERE:
Attach/Upload:
*
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of
ATTACH PICTURES OF EMPLOYEE ACCIDENT/INJURY HERE :
Attach/Upload:
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Submit
Should be Empty: