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    Employer's Report of Work Injury and Illness
Property/Liability Report Form Fields marked in BOLD are required
Person Completing This Form:
Phone:
Date of Accident:
Time of Accident:
Insured's Name:
Address:
City:
State:
Zip:
Phone:
Claimant's Name:
Address:
City:
State:
Zip:
Phone:
Check One: Auto
General Liability
Property
Student Accident? Yes
No
Brief Description of Incident:
Location of Incident:
If Auto, Insured Driver and Number:
Driver:
Number:
Witnesses and/or injuries:
Insd. property damaged (make and model or describe property) and where located:
Clmt. property damaged (make and model or describe property) and where located:
Additional Comments:
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