First Report of Injury / Incident
If this is a medical emergency, please dial 911.
Name of Injured Employee
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Inury/Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Inury/Incident
*
Hour Minutes
AM
PM
AM/PM Option
Time Inury/Incident Reported to Supervisor
*
Hour Minutes
AM
PM
AM/PM Option
Name of Supervisor
*
First Name
Last Name
Type of Incident
Please Select
Accident / Injury
Property Damage
Both Injury and Damage to property
Injury to Other (Customer)
Details of Incident(part of body/which equipment affected/how did it occur):
*
Description of Injury in Detail:
Witness(es) (If none, write "NONE"):
*
Was First Aid provided on site to Injured Person ?
Please Select
Yes
No
Refused
N/A (property damage only)
Was a claim filed with Hanover Insurance Company
Please Select
Phone 800-628-0250 -- Policy #WZC-M058357-00
Name of Representative from Hanover
Claim Number
Were you instructed to seek treatment?
Please Select
Yes
No
N/A
If so, please provide the facility name and address:
Would you like to add any photos to the report?
Submit
Should be Empty: