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| 发布时间：2006-8-10 8:47:07 | 信息来源：本站原创 | 浏览： | |
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HOME ADDRESS ___________________________________________
__________________________________________
__________________________________________
STATUS OF INJURED PERSON __________________________________________
DATE OF ACCIDENT __________________________________________
TIME OF ACCIDENT __________________________________________
LOCATION OF ACCIENT __________________________________________
DETAILS OF INJURY __________________________________________
CAUSE OF ACCIDENT _________________________________________ (HOW DID IT HAPPEN?)
__________________________________________
__________________________________________
TAKEN TO HOSPITAL YES [] BY AMBULANCE [] BY CAR []
(Please tick) NO []
DO YOU CONSIDER THE COMPANY IS AT FAULT? YES/NO(delete which does not apply)
IF ’YES’ GIVE REASON _________________________________________
__________________________________________
ACCIDENT REPORTED BY __________________________________________
COMPANY STATUS __________________________________________
DATE SIGNATURE
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