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
 can).____________________________________________________________________
 ________________________________________________________________________
 ________________________________________________________________________
 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)

Notes

								
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