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