QBE Home
:
Accident Reporting
FORM AR/1
Persons Affected :
Please Select
Employee
Visitor
Contractor
Sex :
Please Select
Male
Female
Name of Injured Person :
Age :
Please Select
0-6m
6-12m
1-10
10-18
18-25
25-35
35-45
45-55
55+
Address :
Telephone Number :
Date and Time of Injury or Incident :
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January
February
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September
October
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December
2007
2008
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Date and Time Reported :
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31
January
February
March
April
May
June
July
August
September
October
November
December
2007
2008
1
2
3
4
5
6
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8
9
10
11
12
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14
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17
18
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20
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24
:
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41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Location :
Please Select
Covall Wells
Bristol
Manchester
Glasgow
Birmingham
Stafford
Leeds
Hessle
Dublin
Home Based
London Plantation Place
London 88 Leadenhall Street
London 65 Leadenhall Street
London Seething Lane
Norwich
Occupation :
Supervisor :
Kind Of Accident :
Contact With Moving Machinery
Struck by moving, including flying/falling, object
Struck by moving vehicle
Strike against something fixed or stationary
Injured while handling, lifting or carrying
Slips, trips or falls on same level
Falls from a height up to and inc 2 metres
Falls from a height over 2 metres
Falls from a height not stated
Tripped by something collapsing/overturning
Drowning or asphyxiation
Exposure to, or contact with, a harmful substance
Exposure to fire
Contact with electricity or electrical discharge
Injured by an animal
Acts of violence
Other kind of accident - please state :
Injuries not classified by kind
Area of the Body Affected :
Front Of Body
Rear of Body
Head
Shoulders
Arms
Hands
Torso
rear
Legs
Buttocks
Feet
Eyes
Ears
Skin
Genitalia
Details Of The Injury (be specific) :
How Caused :
Treatment Given :
Sent :
Back To Work
Home
Doctor
Hospital
Your name:
Witness 1 :
Witness 2 :
Upload Image
gif / jpeg files only
