All information collected herein is governed by organizational privacy policies and utilized solely for claim adjudication and workplace safety improvement purposes.
Employee Identification Number
Full Legal Name
Primary Department Assignment
Sales & Business Development
Customer Success & Support
Engineering & Product
Marketing & Communications
Finance & Operations
Human Resources
Legal & Compliance
Other
Specify Department Name
Current Job Role/Title
Primary Remote Work Location Type
Designated Home Office
Coworking Space Subscription
Public Library or Cafe
Client or Partner Site
Other Off-Premises Location
Describe the alternative work location
Complete Remote Work Address (including floor, unit, or room number)
Has this remote location been pre-approved and verified by the Workplace Services team?
Provide justification for using an unverified location and any prior correspondence
Exact Incident Occurrence Date & Time
Authorized Travel Departure Time from Remote Work Base
Intended Destination Address for Corporate Errand
Primary Transportation Mode Utilized
Personal Automobile
Rental Vehicle
Public Bus or Train
Bicycle or E-Scooter
Walking
Ride-Hail Service
Corporate Shuttle
Other
Specify Transportation Mode
Corporate Errand Purpose Category
Client Meeting or Visit
Supply or Equipment Procurement
Document Delivery or Collection
Banking or Financial Transaction
Corporate Event Attendance
Training or Certification
Other Business-Related Task
Describe the specific business task
Was this travel explicitly authorized in advance by your direct supervisor or department head?
Authorizing Manager Name and Title
Explain the circumstances under which travel was undertaken without explicit authorization
Estimated One-Way Travel Distance (in kilometers)
Environmental Conditions at Incident Time (select all applicable)
Clear Daylight
Darkness with Street Lighting
Darkness without Lighting
Rain or Drizzle
Heavy Rain
Snow or Ice
Fog or Mist
Strong Winds
Extreme Heat
Extreme Cold
Road or Pathway Surface Condition
Dry and Well-Maintained
Wet but Navigable
Icy or Snow-Covered
Uneven or Cracked Pavement
Under Construction
Gravel or Unpaved
Obstructed by Debris
Other Hazardous Condition
Provide a meticulous, step-by-step factual reconstruction of the incident. Accuracy and completeness are critical for proper claim evaluation and future risk mitigation.
Detailed Chronological Incident Description (who, what, where, when, how)
Did the incident result in personal injury or bodily harm?
Describe the immediate injury symptoms and affected body regions
Did the incident result in damage to property, equipment, or vehicles?
Describe the damaged property and visible extent of damage
Pre-Incident Activity Timeline (15 minutes before event)
Time | Activity or Action | Location | Distraction Present? | ||
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A | B | C | D | ||
1 | 8:45 AM | Departed home office | Residential driveway | ||
2 | 8:50 AM | Driving to supplier | Highway 101 North | ||
3 | 9:00 AM | Navigating exit ramp | Industrial Boulevard | ||
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Were there any witnesses to the incident?
Witness Information
Witness Name | Contact Information | Relationship to Claimant | Witness Statement Summary | ||
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Name and Title of Manager Who Authorized the Corporate Errand
Upload Authorization Documentation (email, travel request form, or written approval)
Is the task authorization documentation disputed or unavailable?
Detail the dispute or explain why authorization cannot be produced
Did you receive a safety briefing or risk assessment for this specific errand?
Summarize the safety instructions provided
Describe any safety concerns you raised or assumed
Was a formal risk assessment documented for this travel assignment?
Explain why a risk assessment was not completed prior to travel
Primary Root Cause Category (select the most appropriate)
Environmental Hazard
Vehicle or Equipment Failure
Human Error or Distraction
Inadequate Safety Training
Lack of Proper Personal Protective Equipment
Unauthorized Route or Method
Third-Party Negligence
Other Contributing Factor
Elaborate on the other contributing factor
Contributing Factors to Incident (select all that apply)
Mobile Phone Use
Fatigue or Drowsiness
Unfamiliar Route
Time Pressure or Urgency
Inadequate Lighting
Poor Weather Conditions
Mechanical Issue
Health-Related Issue
Other Distraction
This section determines compensability under organizational policies and identifies potential third-party recovery opportunities. Complete with precision to ensure appropriate coverage allocation.
Did you sustain any physical injury or bodily harm from this incident?
Injury Type(s) Sustained (select all applicable)
Sprain or Strain
Fracture or Break
Cut or Laceration
Bruise or Contusion
Burn (Thermal or Chemical)
Concussion or Head Injury
Back or Spinal Injury
Repetitive Stress Injury
Psychological Distress
Other Injury Type
Specify Other Injury Type
Specific Body Regions Affected (select all applicable)
Head or Neck
Shoulder or Upper Arm
Elbow, Forearm, or Wrist
Hand or Fingers
Chest or Abdomen
Back (Upper, Mid, or Lower)
Hip or Pelvis
Thigh or Knee
Lower Leg or Ankle
Foot or Toes
Multiple Regions
No Physical Injury
Subjective Severity Rating of Injury (1 = Minor, 5 = Life-Threatening)
Medical Attention Sought
No Medical Attention
Self-Treatment Only
Outpatient Clinic Visit
Emergency Room Visit
Hospital Admission
Specialist Consultation
Ambulance or Paramedic Response
Clinic or Facility Name
Hospital or Emergency Facility Name
Hospital Name and Admission Date
Specialist Type and Name
Responding Emergency Service and Incident Number
Summary of Medical Treatment Received and Prognosis
Has a formal workers' compensation or occupational injury claim been filed?
Claim Reference Number
Explain why a claim has not been filed
Was a third party (non-employer) involved in or responsible for the incident?
Third-Party Involvement Type
Other Vehicle Driver
Property Owner or Manager
Municipal or Government Entity
Product or Equipment Manufacturer
Service Provider or Contractor
Member of the Public
Other Third Party
Specify Third-Party Type
Third-Party Insurance and Contact Information (if applicable)
Third Party Name | Insurance Company | Policy Number | Contact Phone | Liability Accepted? | ||
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Were police, security, or other regulatory authorities notified?
Authority Notification Details
Authority Name | Officer or Report Number | Notification Date/Time | Upload Official Report | ||
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Upload Photographs of Incident Scene, Injuries, or Property Damage (maximum 10 images)
Document all corporate-owned or leased assets damaged during the incident. Provide detailed inspection data to facilitate accurate cost recovery and data security risk mitigation.
Did the incident involve damage to corporate IT equipment or other physical assets?
Damaged Asset Inventory and Assessment
Asset Type (Laptop, Phone, Monitor, etc.) | Serial Number or Asset ID | Ownership | Description of Damage | Estimated Repair Cost | Estimated Replacement Cost | Contains Sensitive Corporate Data? | ||
|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | ||
1 | Laptop Computer | SN-7845-9923 | Corporate Owned | Cracked screen and dented chassis | $450.00 | $1,800.00 | Yes | |
2 | Mobile Phone | SN-4456-7823 | Leased from Vendor | Water damage, will not power on | $0.00 | $1,200.00 | Yes | |
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Is there a concern that sensitive corporate data may have been compromised, lost, or exposed?
Potential Data Exposure Types (select all that apply)
Customer Personal Information
Employee Personal Information
Financial or Payment Data
Intellectual Property or Trade Secrets
Strategic Business Plans
System Credentials
No Data Exposure Confirmed
Immediate Actions Taken to Secure Data or Prevent Further Loss
Recommended Disposition for Primary Damaged Asset
Repair and Return to Use
Replace with Equivalent Model
Replace with Upgrade Model
Decommission and Dispose
Await Insurance Adjuster Decision
Total Estimated Financial Impact (sum of all repair/replacement costs)
Has a separate corporate insurance claim been filed for asset damage?
Insurance Claim Number
Upload Clear Photographs of All Damaged Assets (including serial numbers where visible)
This final section requires dual-authority validation to certify claim classification, identify mandatory reporting obligations, and authorize final disposition. Both signatures are mandatory for claim closure.
Official Incident Classification Determination
Recordable Occupational Injury Illness
First-Aid Only Incident
Property Damage Only (No Injury)
Near Miss (No Injury or Damage)
Unauthorized Travel (Not Compensable)
Pending Investigation
Does this incident trigger mandatory external regulatory reporting obligations?
Regulatory Reporting Jurisdictions and Agencies
National Labor Safety Authority
Regional Workers' Compensation Board
Transportation Safety Bureau
Environmental Protection Agency
Local Municipal Authorities
Industry-Specific Regulator
Multiple Jurisdictions
Are corrective or preventive actions required to avoid recurrence?
Required Corrective Actions and Accountability
Action Item Description | Responsible Party | Target Completion Date | Priority (1=Low, 5=Critical) | ||
|---|---|---|---|---|---|
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HR Operations Manager Review Completed
Explain why HR review is not completed
HR Operations Manager Review Comments and Recommendations
HR Operations Manager Digital Signature and Date
Environmental Health & Safety (EHS) Lead Review Completed
Explain why EHS review is not completed
EHS Lead Technical Assessment and Safety Recommendations
EHS Lead Digital Signature and Date
Final Claim Disposition Status
Approved for Full Processing
Approved with Conditions
Referred to Legal Counsel
Denied (Not Work-Related)
Denied (Unauthorized Activity)
Under Further Investigation
I acknowledge that I have been informed of my rights to appeal this determination and understand the applicable procedure
Form Completed By (Name and Role)
Form Completion Date
To configure an element, select it on the form.