WORKERS’ COMPENSATION
Witness Report
Claim No.
Employee
Employer
Date of Injury
Name
Address
Employer
On
Phone
Employer Phone
, 20
, at
a.m./p.m., I was at (state clearly your location)
when an accident involving the above employee is alleged to have occurred.
(check one)
I saw the accident and it occurred in the following manner:
I did not see the accident, but information was given to me by
(injured employee or witness) indicates it occurred as follows:
I have no knowledge of the alleged incident.
Signature
Date