Personal Injury Report by ReadyBuiltForms


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									                                 Personal Injury Report

To be completed by the injured person.

Information about you
Your name _______________________________ Daytime phone __________ Your age ________
Home address ________________________________________________________________
Your employer ____________________________ Your occupation ___________________________

Information about the accident
 1. Was the accident job-related? ___
    If yes, please see your employer about workers’ compensation benefits.
 2. Where did the accident occur (be as specific as you
 3. What were the date and time that the accident occurred? __________________________
 4. What was the nature of your injury?____________________________________________
 5. Please describe what happened. ______________________________________________

6. What were you doing when the accident happened? ______________________________
7. What were the weather conditions when the accident occurred? _____________________
8. Did anybody see the accident happen? ____
 If so, provide their names and phone numbers.
 Name ____________________________________________ Phone__________________________
 Name ______________________________________ Phone _________________________
 Name ______________________________________ Phone _________________________
 Name ______________________________________ Phone _________________________

Follow-up information
 1. Did you receive m edical treatment? _____ If so, on what date(s)? ____________________
  Who was the medical provider? _________________________________________________
 2. As of today (the date you are com pleting this form), do you still have any sym ptoms
related to this accident? If so, please describe them. __________________________________

Your signature __________________________________ Date _________________________

Investigation requested (date)


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