Details of Worker Injuired or DeceasedFirst NameLast NameDate of BirthAddressDetails of AccidentDate of AccidentTime of AccidentPlace of AccidentWas worker injured in the course of employment?YesNoDescribe how the accident happenedWhere was the worker taken after the accident?when was the accident reported to you?Who reported the accident?Details of InjuryWhat were the worker's injuries?Date first attended to by doctorName of attending DoctorEmployment DetailsWas the worker on your payroll when the accident occurred?Yes NoHave you paid the ACC levy on this workers salary?YesNoDate workers was first employedOccupation of injured workerWorkers NPF No:Present pay rateNormal working hours per weekWill worker likely lose any earnings as a result of the accident?YesNoSubmit Form