Please fill out this report in as much detail as you can to support your claim.

Accident at Work

Name

Email

Phone

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date of birth

National Insurance number

Date of accident

Time of accident

:

Employer at time of accident

Are you still in that employment?

Yes

No

Employer’s liability insurance details (insurer and policy number)

Accident location

Description of accident (as much detail as possible)

Details of injuries

Are the symptoms/treatment ongoing?

Hospitals/GP attended and dates of attendances

Was an accident report booklet completed?

Full names and addresses of accompanying persons/witnesses

You position within employer company / your job title:

Name of General Manager:

Name & work address of supervisor:

Are you aware if the accident has been reported to Health & Safety Executive?

Please provide photographs of your injuries and/or at the location of accident e.g. machinery/tools

Max. file size: 256 MB.

Who do you think is to blame & why?

Previous relevant experience with a previous employer?

What was the standard practice e.g. tools used in a particular way/guard on machinery removed?

Are you aware of any other accidents of similar nature?

Are you aware of any risk assessments undertaken by your employer?

Were you given any safety booklets/information/training by employer?

Was Personal Protective Equipment provided and used? Was it sufficient?

Have you suffered any loss of earnings?

Any other expenses incurred? e.g. travel to medical appointments, private physiotherapy, damaged items etc.?

Are you a member of a Trade Union?

Yes

No

I don't know

Do you have legal expenses insurance?

Yes

No

I don't know

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Accident at Work Report Form

Please fill out this report in as much detail as you can to support your claim.

Accident at Work