Work-related accident report

Notes on reporting / Data protection

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Fields marked with * are mandatory.

Details of the insured and injured person

Select employment or student status*

First name*

Last name*

Date of birth*

Street*

House number*

Address line 2

Country*

Postal code*

City*

Telephone number

Gender*

Nationality*

Student number*

Legal representative

Does the insured person have a legal representative?*

Last name, first name of legal representative*

Contact details (address)*

Telephone number

Employment relationship

Temporary agency worker*

Trainee / apprentice*

Holds a marginal/minor employment (mini-job)*

Entrepreneurial status

The insured person is:*

Relationship to the business owner*

Health insurance

Type of health insurance*

Health insurance provider*

Country

Postal code

City

Accident details

Was this a fatal accident?*

Date of accident*

Time of accident

Place of accident*

Please enter as precise a location and street address with postal code as possible (e.g., building/room or address).

Additional information (if applicable):

Circumstances of the accident

Did a violent incident occur (e.g., physical or sexual assault)?*

What kind?*

e.g., attack, fight, robbery, threat, (attempted) rape

Detailed description of the accident*

Please specify:
a) Object involved (e.g., vehicle, door, part of laboratory or workshop equipment, stairway)
b) Activity of the injured person at the time of the accident (e.g., commute to/from the university, internship, exam, lab experiment)
c) How the accident happened (e.g., struck by vehicle, fell, burned, crushed)
d) Probable cause of the accident (e.g., inattention, defect in the object involved, fault of a third party)
e) For traffic accidents, also provide the police station that took the report

The information is based on the account of the insured person.*

Injury

Injured body part(s)*

Please list the most severely affected body part first (e.g., right upper arm, chest, jaw).

Type of injury*

e.g., cut, bruise, burn, chemical burn, crush injury.

Commuting accident

Accident location*

If other location, where?*

Workplace on the day of the accident (full address)*

Street, house number, postal code, city.

Where were you coming from when the accident happened (e.g., workplace or home with full address)*

Street, house number, postal code, city.

Destination of the trip (full description and address)*

Destination & full address.

Direction of the commuting accident*

If the accident occurred while going to the workplace:

Time left home*

Usual start of work:*

If the accident occurred while returning from the workplace:

Time left workplace*

Usual end of work:*

Which route do you normally take between home and workplace (exact locations and street names)

Please describe the sequence (places/stops), main streets/turns and the typical route.

Usual total distance (km)*

Usual total travel time (hh:mm)*

The route is usually traveled by*

Other (usual mode of transport):*

Actual route on the day of the accident

Comparison with the usual route*

If different: exact locations and street names*

The route was actually traveled by*

Other (actual):*

Was this, to your knowledge, a detour?*

How much longer than the usual route — distance (km)*

How much longer than the usual route — time (hh:mm)*

Why did you take the detour?*

Did you run errands or intend to run errands on the way?

Did you run errands or intend to run errands on the way?*

If yes, for whom?*

Which errands and where? (exact description and address)*

Did you visit or intend to visit restaurants or similar, relatives, acquaintances? (if applicable, give exact description and address)*

For what purpose?*

Did you visit or intend to visit a doctor, authorities, etc.? (if applicable, give exact description and address)*

For what purpose?*

Duration of stay from (time)*

until (time)*

The accident occurred*

How can any time discrepancy be explained?

Who accompanied you (name and address)?

Medical treatment

Was medical assistance needed?*

Initial medical treatment was provided by*

Please provide the name and address of the doctor/hospital who provided first aid or initial treatment.

Name*

Street*

House number*

Address line 2

Country*

Postal code*

City*

Was hospital treatment required or given?*

Start of treatment*

Period of stay from*

until*

Does the work-related accident result in incapacity for duty?*

From*

Until*

Accident witnesses

Are there any accident witnesses?*

Last name, first name*

Contact details (address)

Can this person testify about the accident?*

Was the accident investigated by the police or public prosecutor?*

Provide the investigating authority (name and address) and file number*

Attachments related to the accident

Police report (max. 2 MB, PDF/JPG/PNG)

Medical certificate for the recognition of an official accident (mandatory) (max. 2 MB, PDF/JPG/PNG)*

Receipts and invoices for medical and emergency costs (max. 2 MB, PDF/JPG/PNG)

Witness statements, if applicable (max. 2 MB, PDF/JPG/PNG)

Proof of the value of damaged items or clothing, including age, period of use and purchase price (if applicable) (max. 2 MB, PDF/JPG/PNG)

Additional information

Start of working/study time at the facility on the day of the accident*

(Planned) end of working/study time at the facility on the day of the accident*

Employed/working at the time of the accident as*

The insured person is regularly employed in the following part of the organization*

Since when has the insured person performed this work?*

Did the insured person interrupt work / attendance at the facility after the accident?*

Work / attendance at the facility stopped on*

Work / attendance at the facility stopped at*

Did the insured person resume work / attendance at the facility?*

Resumed on*

Additional information

Will compensation be claimed for private property damage under Section 83 LBG NRW?*

Description of the property damage caused by the accident*

Is there fault of a third party (third-party liability)?*

Information about the person at fault

Last name, first name

Address details

Vehicle license plate

Name of insurer

Bank details*

Account holder*:

Name of the Bank:*

IBAN:*

BIC:*

Anti-spam protection: Please answer the arithmetic question*

What is 7 x 2 ? $Refresh icon$