Elumina - Quicksafe

Total Claims Solutions

Details of the incident

Kind of incident*:
Incident type*:
Hazard type*:
Near miss type*:
Incident classification:
Description*:
Date and time of incident*:	:
Date reported*:

Kind of incident*:

Incident type*:

Incident classification:

Description*:

Date and time of incident*:

Date reported*:

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Reporting person details

Relationship*:
Company name*:
Title*:
Given name*: Please specify the given name (i.e. not an alias)
Family name*:
Street address*:
Suburb*:
State*:
Postcode*:
Telephone*:
Email:

Relationship*:

Title*:

Given name*:
Please specify the given name (i.e. not an alias)

Family name*:

Street address*:

Suburb*:

State*:

Postcode*:

Telephone*:

Email:

* indicates required fields

Location incident occurred

Division*:	Select one... Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia
Exact location*: Please complete the Company name

Division*:

Exact location*:
Please complete the Company name

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Injured person details

Given name:
Family name:

Given name:

Family name:

Injury details

Description of injury:

How did the injury occur:

Injury a result of:

Nature of injury:

+ -

Injured body part:

+ -

Cause of injury:

+ -

Medical treatment:

Do you have anything further to add:

Notification

This will send a notification of this reported incident to the specified email address.

Supervisor email address*:

Supervisor email address*:

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