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
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
Complete Remote Work Address (including floor, unit, or room number)
Has this remote location been pre-approved and verified by the Workplace Services team?
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
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
Was this travel explicitly authorized in advance by your direct supervisor or department head?
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?
Did the incident result in damage to property, equipment, or vehicles?
Pre-Incident Activity Timeline (15 minutes before event)
Time | Activity or Action | Location | Distraction Present? | |
|---|---|---|---|---|
8:45 AM | Departed home office | Residential driveway | ||
8:50 AM | Driving to supplier | Highway 101 North | ||
9:00 AM | Navigating exit ramp | Industrial Boulevard | ||
Were there any witnesses to the incident?
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?
Did you receive a safety briefing or risk assessment for this specific errand?
Was a formal risk assessment documented for this travel assignment?
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
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?
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
Summary of Medical Treatment Received and Prognosis
Has a formal workers' compensation or occupational injury claim been filed?
Was a third party (non-employer) involved in or responsible for the incident?
Third-Party Insurance and Contact Information (if applicable)
Third Party Name | Insurance Company | Policy Number | Contact Phone | Liability Accepted? | |
|---|---|---|---|---|---|
Were police, security, or other regulatory authorities notified?
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?
Is there a concern that sensitive corporate data may have been compromised, lost, or exposed?
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?
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?
Are corrective or preventive actions required to avoid recurrence?
HR Operations Manager Review Completed
HR Operations Manager Review Comments and Recommendations
HR Operations Manager Digital Signature and Date
Environmental Health & Safety (EHS) Lead Review 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