
Date of the accident _________________________
Names of the individual(s) involved ________________________
______________________________________________________
Employment status (i.e., full-time, part-time, contractor): _____________
Place of the accident (location, street address/intersection, or any other location description) ____________________________________________
What happened: ________________________________________
______________________________________________________
Vehicles or equipment involved: ___________________________
______________________________________________________
Weather conditions: _____________________________________
Was law enforcement involved? Citation(s) issued? Nature of violation?
______________________________________________________
Injuries:_______________________________________________
| Name | Injury? | Hospitalized? | W/C claim? |
Damage to property _____________________________________
| Witness Name | Address | Telephone |