Name of Customer Injured or Property Damaged:

First Name Last Name

Phone # of Customer Injured or Property Damaged:

Address Injury / Incident Took Place:*

Street Address

Street Address Line 2

City State

Zip Code

What person/substance/object caused the injury?*

Safety Equipment that was required (if none, write "None"):*

Safety Equipment that was used (if none, write "None"):*

Was First Aid provided to Injured Person?*

Yes No Refused N/A (Property Damage only)

Injured Person was treated by:*

Were the Police called (Property Damage)?

Yes Refused by Customer N/A

Estimated value of Damaged Property

Take photo of Injury / Damaged Property

Photo 2

Please call or text Jay Groth, HR Manager with Jay Consulting Group, with any questions or for status on Return to Work at (616) 541-5081, JGroth@jayinc-hr.com.

First Report of Injury / Incident

First Report of Injury / Incident