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EMPLOYEE LIABILITY - Accident Report Form
INSTRUCTIONS
To enable Insurers to fulfil its obligations under the terms of the policy this form must be completed and submitted to the appropriate Area Claims Office together with all relevant accident documentation e.g. letter of claim, internal investigation report, etc. Details of any serious accident should be notified immediately irrespective of whether a claim has been made.

In the event of a fatal accident the Company should be notified immediately by telephone or facsimile in order that representation at the enquiry into the death can be arranged.

No payment, offer or promise of payment or admission of liability in any way should be made. No inspection of plant or machinery should be allowed unless agreed by Iron Trades Insurance.

Any communication received about the accident should not be answered but sent to Iron Trades Insurance Immediately.

Policy Number *
Name of Insured:
Address
Post Code Telephone No:
Contact Name Telephone No:

Name of Employee:
Address
Post Code Telephone No:
Contact Name Telephone No:
Date of Accident: Time Of Accident:

Place of Accident
Nature of Injury or disease Date returned to work
Date Ceased Work
Circumstances of accident/disease
Was the accident/disease caused by any other party? If yes, please provide details:
YesNo

In addition to the accident description please also provide copies of :-
o Your Accident Book Entry
o Any Statutory Health and Safety Notification
o Any internal investigation report

Name of Foreman/Supervisor
Name and Address of Witnesses
Email Address *
This email address will be used for correspondence regarding this On-Line form and for no other purpose.

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