Park Construction Co.



	Report of Work Injury

REPORT OF WORK INJURY

IMPORTANT!

All work related injuries, utility line damage or accidents must be reported immediately. Fill out the accident reporting form and call the information into the office or safety director immediately. FAX or mail a copy of the completed form into the office within 24 hours.

To report an accident during normal business hours contact Tammy Johnson at 701-662-2680.

To report an accident after normal business hours contact the Safety Director at 701-741-3092.

It is critically important to report accidents immediately. Insurance companies do have the right to refuse claims that are not reported in a timely manner.

This form is to be filled out immediately for every injury on the job.

Employee Injured
Name:
Address:
Phone:
Date of Birth:
Soc. Sec. No.:
Date of Hire:
Date Start at This Job:
Place of Accident
Date of Accident:
Time:
Job # and Location:
Exact Place Where Accident Occurred:
Nature of Injury
What was injured?
How severe is injury?
How did accident occur?
Will there be time lost other than day of injury?
Treating Physician
Name of Clinic or Hospital:
Name of Doctor:
Telephone No.:
Safety Action Taken
What caused accident?
What was done to correct situation?