Details of Worker Injuired or Deceased
First Name
Last Name
Date of Birth
Details of Accident
Date of Accident
Time of Accident
Place of Accident
Was worker injured in the course of employment?
Describe how the accident happened
Where was the worker taken after the accident?
when was the accident reported to you?
Who reported the accident?
Details of Injury
What were the worker's injuries?
Date first attended to by doctor
Name of attending Doctor
Employment Details
Was the worker on your payroll when the accident occurred?
Have you paid the ACC levy on this workers salary?
Date workers was first employed
Occupation of injured worker
Workers NPF No:
Present pay rate
Normal working hours per week
Will worker likely lose any earnings as a result of the accident?