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WORKMEN COMPENSATION ACCIDENT REPORT/CLAIM FORM
policy holder
name (in full)
occupation
address
in connection with what trade or business did you employ the injured person?
are you insured elsewhere against this risk? if so, give name of company
particulars of injured person  
name
date of birth
occupation
married/single
address
number of children under 15
is (s)he related to you?
yes no
if so state relationship
does (s)he reside with you?
yes no
is (s)he in your direct employ?
yes no
is (s)he in your sole employ?
yes no
since what date?
if in the service of a sub-contractor, give the name and address of the sub-contractor
is (s)he an insured person under the national health insurance act?
yes no
if so, state name and address of approved society and membership number
name
address
the accident  
details of occurence
date
hour
place
date Injured Employee ceased work
date
hour
Description of accident occurence
Precise duties of the Injured Employee at time of Accident occurrence
General nature of the work going on?

Machinery in use in connection with the work?
Date the injured person first reported the accident?
To whom was it reported?
Did the accident occur during his/her working hours?
Was (s)he sober?
Was (s)he guilty of any misconduct or disobedience to others?
If so, give full particulars
Was the accident due to negligence upon the part of any person?
If so, give name and state whether such person is in direct employ?
Names and addresses of any witnesses of the accident
the injury  
State very fully the nature and extent of the Injury
N. B. IF TO A LIMB, STATE WHETHER RIGHT OR LEFT
left right
Is the Injured Employee able to attend to any portion of his/her work
yes no
If so, what is the likely duration of incapacity?
Where was (s)he taken after the accident?
Where is (s)he now?
Name and address of Doctor in attendance
general information  
Give all such other details in respect of the Accident and the Injured Employee as would be of assistance to the Company

STATEMENT OF WAGES earned by the Injured workman for twelve months prior to the date of the Accident or for such shorter period as he/she may have been in the Employer's service.

 

NOTE: Please state reason for any period of absence from month.
week ended wages week ended wages week ended wages
  forward forward
1 19 37
2 20 38
3 21 39
4 22 40
5 23 41
6 24 42
7 25 43
8 26 44
9 27 45
10 28 46
11 29 47
12 30 48
13 31 49
14 32 50
15 33 51
16 34 52
17 35
18 36
forward total amount earned in

weeks
      average weekly earnings =  

State if any consideration other than cash wages is received by injured person:

Nature of consideration
Cash Value per week
I/We the undersigned Policyholder hereby declare that the above statements and facts are true and that I/we have not withheld from the company any information within my/our knowledge connected with the claim.
do you agree
yes no
 

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