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Incident Investigation Form

  1. Call in all accidents as soon as possible, but no later than 24 hours after the incident to the Travelers' Claim Office at 1-800-238-6225.

  2. Be prepared to give the operator as much of the following information as possible.

  3. The Risk Management Office will automatically be notified of your injury upon the submission of this form, and will contact you shortly regarding the next steps in the process.

Full Legal Name
e.g., Director, Manager, Coordinator, etc
Primary Number
Primary E-mail
Full Legal Name
7-digit Number
mm/dd/yy
Not alias or forwarding address
If applicable
(xxx-xxx-xxxx)
(xxx-xxx-xxxx)
Position Description
mm/dd/yy
  mm/dd/yyyy
Indicate date the injury occurred, not when it was reported.
Building and/or Room Number
mm/dd/yy
(If yes, date returned)
(e.g. head, neck, arm, leg)
(e.g. fracture, sprain, laceration)
Include the cause of the accident (e.g. slip, lifting, chemical), any contributing factors, equipment involved, etc. Also include the names and numbers of any witnesses or involved parties. If there are circumstances that give you reason to suspect that the above injury may be fraudulent, please describe and notify the Risk Management Office at 202-885-6813.