This form complies with OSHA’s Supplementary Record of Occupational Injuries and Illness Form 101, and must be completed
within six working days of an incident and kept in the establishment for five years to comply with Public Law 91-596 and OSHA
requirements. This accident report will aid in the investigation by your carrier of any injury or illness.
Date of this Report / /
Case or File #
(IF DIFFERENT FROM MAILING ADDRESS)
_________________________________________________________ Job Title/Occupation
Department ___________________________________ (Regular department or division where employee is regularly employed)
Gender: □ Female □ Male
Social Security #
Employee Insurance #
Facts of Accident/Illness
□ Illness □ Injury
□ Yes □ No
Did incident occur on employer’s premise?
□ Yes □ No
If yes, address of plant/establishment
Note: If fatality occurred or more than 3 employees are
hospitalized, OSHA must be notified within 8 hours.
Where on premises did incident occur?
If no, address where incident occurred
(IF INJURY OCCURRED WHERE NUMBER AND STREET ARE UNIDENTIFIABLE, PROVIDE PLACE REFERENCES.)
Date of Accident/Illness
Time of Accident