Non-Employee Injury Report - CoAction Specialty

This report is to be completed when a person (non-employee) is injured on company premises.

Person’s name: ____________________________________Date of injury: ____/____/____

Why was person on our property?_______________________________________________

What was he/she doing when injured?___________________________________________

_________________________________________________________________________

Did you witness the accident?  Yes  No

Did the person report the injury immediately after the accident?  Yes  No

Describe what happened:_____________________________________________________

_________________________________________________________________________

What was the person’s physical condition and appearance when the injury was reported to you?

_________________________________________________________________________

What first aid or treatment did you administer, if any?

_________________________________________________________________________

Did you advise the person to seek outside treatment or did you call a paramedic?

_________________________________________________________________________

Has there been any follow-up to the accident by company or injured person?

_________________________________________________________________________

Has our insurance company been notified?

_________________________________________________________________________

Name of Person completing Report: ___________________________________________

Signature: _____________________________________________Date: _____/____/____