Total Claims Solutions

Details of the incident

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

* indicates required fields

Reporting person details

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*:
Exact location*:
Please complete the Company name

* indicates required fields

Injured person details

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*:

* indicates required fields