Workers’ Compensation Insurance Statement of Facts
Employer Information
Employer Name
Policy Number
Address
Phone
Employee Information
Employee Name
Date of Injury
Occupation
Incident Details
Date Reported
Location of Incident
Description of Incident
Nature of Injury or Illness
Nature of Injury/Illness
Medical Attention Provided
Witnesses
Witness Name(s)
Witness Statement(s)
Employer's Statement
Statement
Signature
Employer Signature
Date