ACCIDENT REPORT FORMWORKMEN'S COMPENSATION INSURANCE

Answering these questions does not imply that the Employer admits liability, or that the Workman will makea claim.

PARTICULARS OF ACCIDENT

EMPLOYER'S}

Name.. -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - -- - -- - - - - - - - - - - - - - -- - -- - Policy No- - - - -- - -- - --

Business- - - - - -- - -- - u - - - - - - - u - u - - - - - - - - - - - - - - - - - - - u - -- - - - - - - - 00- n - - - - - - - u - u - - - - - - - 00---

Address- - - - - - - - 00- - - - - - - 00 - - - - 00- - - - - - - - - - - - - - - - - - - -- --- u - - - -Phone No.- - - - - - 00- - -u -- - - - - u-

2- Workman's }Name- - - - - -- - -- - -- - - - - - - - - - - - - - -- - -- - u - - - - - - - - - - - - - 00 - 00 - Occupation u - - - - - 00- - -- - - - - - - - - --

Address -------------------------------------------------------------------------------------

4- Was he in your employ and actually doing workfor you at thetime the accident occured?

If not, please give then the address of the person bywhom he was employed

5- Th ".'cident occured a( u u -- U 00 - - 00 - 00 on theu u - u - u - u- uu - - u day of- - u -- 00 uu u 00- - u - - 20- u u uu _u atu u u- u -- - m

and the disability commenced on theu u u u u - u - u u - - - day ofu 0000 00- 00 - 00 n - -- - n_. 20- - - - - - - - - - - - - - - -- at - - - - - - - - -- - - - - -.m

6- When was the accident first reported to you?

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7-Describe what WORK the injured person was.doing at the time and how the accident actuallyoccured. Indicating whether there was anynegligence. (Please reply fully)

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8- State the nature and extend of the injuries.

9- State whether employee is left or right handed.

10- Has the injured person been treated at a hospital?If so, give dates of admission and discharge }

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11- Give the names of any witness of the accident.

12- Is the workman now doing any work? Ifso, onwhat date did he start? 1

}13- How much longer is the workman likely to be

disabled?

14- Name of Doctor in attendance

15- What is the notice power of the machinery usedon your premises? }

16- How many employees have you?

NOTE: For your protection please note the Condition of your policy which provides that --" The Insured shallnot without the written authority of the Company incur any expense litigation or otherwise or makeany payment settlement of admission of liability in respect of the injury for which the company shall beliable under this Policy."

I hereby declare that the foregoing particulars are correct.

Date- - - - 00 - - -. -. -.. -. -. - - - - - - -- - - - -- Signature- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --

His average monthlyThe age of the How long has he been in your employ? His monthly wages earnings for the previous /Welv.

workman at the time of the months or shorter. accident employ

3- State

- u - u - U - u Years SEE OVER-------------------------------------------- -------------------.

STATEMENT OF WAGES PAID TO

~ - -- ", """" ~ ~*--- --~~-------------------------------------------------------------------------.

For 12 months prior to the date ofthe Accident, or shorter period of employmentIfno wages paid during any month or months, please state the reason

NOTES: (a)~

Value of food, fuel and quarters supplied to the workman by the employer to be inserted if as a resul1of the accident the workman is deprived of them.

(b) Where the workman has been employed for only a short period so that it is not practicable at thedate of the accident to compute his monthly earnings, the average monthly earnings of a personsimilarly employed should be shown in the space for the first month in the above schedule.

Month Wages Value of food, fuel Total Payment Voucher Remarksor quarters Numbers

p p P

1- - - - - - - - - -------- - ---------- - - --------- - - ------------ -------2______--- -------- - ---------- - - --------- - - ------------ -------3- - - - - - - - - -------- - ---------- - - --------- - - ------------ -------4- - - - - - - - - -------- - ---------- - - --------- - - ------------ -------5-- - - - - - - - -------- - ---------- - - --------- - - ------------ -------6______--- -------- - ---------- - - --------- - - ------------ -------7______--- -------- - ---------- - - --------- - - ------------ -------8______--- -------- - ---------- - - --------- - - ------------- -------9-- - - - - - - - -------- - ---------- - - --------- - - ------------ -------

10- - - - - - - - - -------- - ---------- - - --------- - - ------------ -------11______--- -------- - ---------- - - --------- - - ------------ -------12______--- -------- - ---------- - - --------- - - ------------ -------

TOTALS