EMAIL INCIDENT/ACCIDENT REPORT FORM

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Client Name
About the person who had the accident  
Injured person's name
Injured person's department/occupation
Injured person's home address
About the person filling in this form
Your name
Your address
Your occupation
About the accident When it happened and where it happened
Date of incident
Time of incident
In what room or place did the incident happen?
If on site, could it be the subject of an insurance claim?
About the accident Say how the accident happened, give the cause if you can, note any personal injury
Possible cause of the incident
Were there any witnesses to the incident?
How did the incident happen?
Other significant information

Please check that you have covered everything then select