8250 Woodfield Crossing Blvd, Suite 330 Indianapolis IN 46240 www.hjspier.com info@hjspier.com 317-815-2800 (Main Line)	Commercial Lines Claims: 317-815-2803 Personal Lines Claims: 317-815-2802 After Hours Emergency: 317-363-9774

CUSTOMER ACCIDENT REPORT

(Liability Claims)

Injury Date:	Time Incident Occurred:	Date Reported:
Name of Injured Person:
Address:
Telephone Numbers:	H)	C)	W)
Exact Location of Accident:
Describe fully how accident/incident occurred. Please be specific regarding environmental conditions or other factors relating to the cause of the incident:
Did employee/Supervisor inspect area where incident occurred?
List Witnesses and Telephone Nos:
What steps were taken immediately after the incident:
Did person injured obtain medical treatment: Y N	Ambulance Called: Y N
List medical Facilities if treatment obtained:
Employee’s Comments:
Employee’s Signature:
Supervisor’s Signature:
Telephone No where Employee/Supervisor can be contacted: