Name of Parent, Guardian or Family Member (if a minor):

Address (street, city, state, zip code):

Phone: Email Address:

Age: Sex: Job Title:

Last Monthly pay level:

If vehicle or machinery, were you driving? YES: NO:

Was a police or employer report made:

In report, who was found at fault?:

Why was the person found to be at fault?:

If machinery or dangerous condition,
did an outside person/company create it:

Briefly describe the accident:

Describe the extent of your injuries and injuries to any others involved:

Amount of financial harm to date:
Salary loss: Medical Costs: Other:

Have you or your family suffered other harm from these incidents, describe:

Did accident result in a disability that creates special needs at your job?: