Miscellaneous Claims Notes Sample Clauses

Miscellaneous Claims Notes. 1. Any incident that involved injury to persons or property is to be reported to ▇▇▇ ▇▇▇▇▇▇, OCIP Safety Coordinator’s office immediately. 2. Any claims adjuster representing a Contractor/Subcontractor’s normal insurer who seeks to come onto Any Designated Project site must obtain written authorization from ▇▇▇ ▇▇▇▇▇▇, OCIP Safety Coordinator, prior to coming on the site. There will be no exceptions to this stipulation. ZURICH CLAIM REPORTING COVER SHEET Email to: ▇▇▇_▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇.▇▇▇ OR Contact Fax Number: __ _ __ Employee Name Male Femal Date of Birth Ht. Wt. e Employee Address Street City State Zip Code Home Phone Employer Name Address Date of Incident Time AM/PM Jobsite/Area Employee Job Title Length of Employment Weather Condition Shift Supervisor What actions caused or contributed to the incident? What conditions of tools, equipment, or environment contributed to incident? Operating equipment without authority Inadequate guard/barrier/safety device Failure to warn/signal Inadequate/improper protective equipment Failure to secure/lock out/tag out Inadequate warning system Reaching into/servicing equipment in operation Defective or work tools/equipment materials Making safety devices inoperable Congestion or restricted area Used defective equipment Fire or explosion hazard Took unsafe/improper position Hazardous storage method Horseplay, disruptive actions Unsecured against movement Improper lifting or movement Lighting/noise/visual obstruction Other: Environmental/atmospheric conditions No unsafe action Other: No unsafe condition What actions caused or influenced above unsafe acts? What caused or influenced above unsafe condition? Unaware of job hazards Defective/worn from normal use Inattention to hazards Defective/worn from abuse/misuse Unaware of safe method/procedure Housekeeping/cleaning failure Tried to gain or safe time Lack of preventative maintenance Influence of fatigue/illness Inadequate maintenance Influence of emotions/stress Exposure to environment Defective vision/bodily defects Inadequate purchasing Under influence of alcohol or drugs Safety inspection failure Failure to enforce procedures/rules Other: Other: Unknown Describe the nature and extent of injury/illness (body part affected, type of injury, etc.) Was first aid administered? Yes No If yes, what type and by whom Was employee taken to hospital/clinic? Yes No hospital/physician/nurse attending If yes, list name, address and phone number of How did the incident occur? Desc...