EMPLOYEE ACCIDENT REPORT - WORKER’S COMPENSATION All accidents involving Apollo Professional Solutions, Inc. Employees must be reported immediately to Human Resource Manager at (866) APS-EDGE or via email, . Completed form is faxed to Human Resource Manager (603) 890-6668 within 24 hours of Accident. Section II. EMPLOYEE INFORMATION (To be completed by Employee if able) Social Security Number: XXX XXX - – Name: Time in Job (Yrs. /months.): Job Title: City, State, and Zip Code: Home Address: Emergency Contact Name/Number: Home Telephone Number: Section I. GENERAL INFORMATION (To be completed by Employee if able) Company Address: Company working for: Date/Time of the accident: Started work that day: Location of the accident: Nature of Injury / Illness: (Be specific as to cut, break, strain, sprain, bruise, Re-injury - provide original injury date: etc.) Section III. ACCIDENT INFORMATION (To be completed by Employee if able) Location of accident: When was the accident reported: To whom was the accident reported: accident occurred: Employee’s activity when Names of witnesses to accident: Contact Number for Witnesses: INCIDENT SUMMARY: Brief description of how the accident occurred (state exactly what you were doing and any equipment that was involved):
EMPLOYEE ACCIDENT REPORT - WORKER’S COMPENSATION All accidents involving Apollo Professional Solutions, Inc. Employees must be reported immediately to Human Resource Manager at (866) APS-EDGE or via email, . Completed form is faxed to Human Resource Manager (603) 890-6668 within 24 hours of Accident. Section II. EMPLOYEE INFORMATION (To be completed by Employee if able) Name: Social Security Number: XXX – XXX - Job Title: Time in Job (Yrs. /months.): Home Address: City, State, and Zip Code: Home Telephone Number: Emergency Contact Name/Number: Section I. GENERAL INFORMATION (To be completed by Employee if able) Company working for: Company Address: Started work that day: Date/Time of the accident: Location of the accident: Nature of Injury / Illness: (Be specific as to cut, break, strain, sprain, bruise, etc.) Re-injury - provide original injury date: Section III. ACCIDENT INFORMATION (To be completed by Employee if able) Location of accident: When was the accident reported: To whom was the accident reported: Employee’s activity when accident occurred: Names of witnesses to accident: Contact Number for Witnesses: INCIDENT SUMMARY: Brief description of how the accident occurred (state exactly what you were doing and any equipment that was involved):
Accident-Report.docx