Employee Injury Report Form
Please complete the following form if an injury has occurred to an employee on the job:
Employee Injury Report:
Employee Name:
Location of Accident:
Phone Number:
Job Title:
Supervisor Name:
Date of Injury:
Description of Accident:
Description of Injury:
Was Medical Attention Sought?
Yes
No
Where Accident Occurred:
How Accident Occurred:
Contributing Factors:
Witnesses:
How Could Accident Be Avoided:
Additional Information
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All Rights Reserved | Peabody Insurance
(810) 629-1504
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