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ACCIDENT REPORT FORM

DATE OF ACCIDENT :

DEPARTMENT OF ACCIDENT OCCURED :

STARTWORK TIME ON ACCIDENT DAY :

APPROXIMATE ECONOMICAL DAMAGE ARISEN FROM THE ACCIDENT :

NAME :

INCIDENT OR REGISTRATION NUMBER OF THE INSURED :

ACCIDENT VICTIM
AGE (Yaş) :

DUTY DURING THE ACCIDENT :

NUMBER OF DEAD / INJURED BECAUSE OF THE ACCIDENT
:
SLIGHTLY
DEAD INJURED LOSS OF LIMP
WOUNDED

NUMBER OF OFF-DAYS AND WORKERS ON REST DUE TO THE ACCIDENT:

MORE THAN 3
1 DAY 2 DAYS 3 DAYS
DAYS

NAME OF LOSE LIFE NAME OF INJURED

REASON OF THE ACCIDENT NAME OF INTERVIEWEED WITNESS

REPORTED BY APPROVED BY

NAME DATE NAME DATE

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