App Home
Toolbox Talks
Building A Safety Program
Covid-19
Construction Safety
Fleet Management
Grocery Store Safety
Landscape & Excavation Safety
Lifestyle Lessons
Manufacturing Safety
Mechanical & HVAC Safety
Non-Profit Safety
Office Safety
Property Management Safety
Restaurant Safety
School Safety
Warehousing & Distribution Safety
Quizzes
Accident Report Forms
Initial Report
Employee Accident Report
Supervisor Report Form
Safety Meeting Submission Form
OSHA Safety Videos
Safety Manual
Lunch and Learn Materials
Vehicle Inspection Form
Get in touch
555-555-5555
mymail@mailservice.com
Employee Accident Report
Location of Accident:
Name of Injured:
Phone:
Employee's Address:
Date of Birth
Gender:
Male
Female
Marital Status:
Single
Married
Other
Number of Dependents:
Job Title:
Employer:
Employee Classification:
Date of Hire:
Supervisor Name:
Date of Injury:
Time of Injury:
Average Hours Worked Each Day:
Average Hours Worked Each Week:
Paid For The Day of the Injury:
Yes
No
Description of Accident:
Description of Injury:
Where Accident Occurred:
How Accident Occurred:
Contributing Factors:
Witnesses:
How Could Accident Be Avoided:
Acknowledgement of Statement:
Yes
No
Person Reporting Incident:
Date Person Reported Incident:
Upload Signature Images
Upload Signature
Thank you for contacting us.
We will get back to you as soon as possible
Oops, there was an error sending your message.
Please try again later
© 2025
All Rights Reserved | Peabody Insurance
(810) 629-1504
Share by:
