Common use of Miscellaneous Claims Notes Clause in Contracts

Miscellaneous Claims Notes. 1. Any incident that involved injury to persons or property is to be reported to Xxx Xxxxxx, 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 Xxx Xxxxxx, OCIP Safety Coordinator, prior to coming on the site. There will be no exceptions to this stipulation. ZURICH CLAIM REPORTING COVER SHEET Email to: XXX_XXXXXXXXXX@XXXXXXXX.XXX 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? Describe in detail the task the employee was doing when injured or became ill. Include specifics such as equipment, structure tools, materials, objects (size, shape, and weight), people involved in the task, positions, distances, rate of movement, sequence of events, etc. (Attach any additional information comments, documentation of interviews, sketches, pictures, etc. as necessary) Type of exertion/body motion during injury: Pull Lift Bend Reach Twist Other Was this the employee’s regular job? Yes No How much experience does this employee have on this job? Was the employee trained in this job or task? Yes No When was last training on this task? Was this the employee’s first job-related injury or illness? Yes No If no, briefly describe previous injuries (date, nature, extent, etc.) Hours of overtime worked in last 24 hours Did this possibly contribute to incident? If so, describe Does a safety rule or policy apply to this task? Yes No If yes, describe rule and how employee followed or violated Does a specific procedure for task exist? Yes No If yes, describe procedure briefly and if it was followed Is protective equipment required for this task? Yes No If yes, describe equipment, if it was used, if it was adequate/functioned properly, and if the employee(s) were trained on it. Is there possibly any third party which contributed to the incident? (Other contractors, employee, etc.) Yes No If yes, describe. Did any unsafe physical/environmental conditions exist? Yes No If yes, describe conditions (physical , mechanical, electrical, etc.) which contributed to the incident Is material handling equipment required for this task? Yes No If yes, was it used and did it function Reinstruction of employee(s) involved Do/revise Job Safety Analysis Repair/replace/modify equipment Preventative instruction of others who do job Revise/establish safety rule Improve clean-up procedure Training of employee(s) Reassign employee to another job Improve inspection procedure Action to improve enforcement Require/replace protective equipment Eliminate/reduce congestion Reprimand/discipline of employee(s) involved Install safety guard device Improve design/construction Improve environmental conditions Possible actions to be taken to prevent reoccurrence CORRECTIVE ACTION(S) TAKEN OR PLANNED What was/will be done By Whom Estimated Completion Confirmed Completion Date Date Initial s Incident discussed with employee to prevent reoccurrence? Yes No Date Any disciplinary action taken? Yes No If yes, describe what type. YES NO Incident site reviewed by supervisor with employee (and safety coordinator if applicable.) YES NO Incident review meeting conducted. Attended by YES NO Employee or supervisor reviewed incident with work group. YES NO Employee reviewed injury with safety committee YES NO Project Safety informed of incident Date of Report Prepared by Title Reviewed by Superintendent

Miscellaneous Claims Notes. 1. Any incident that involved injury to persons or property is to be reported to Xxx Xxxxxx, 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 Xxx Xxxxxx, OCIP Safety Coordinator, prior to coming on the site. There will be no exceptions to this stipulation. Zurich Claim Reporting Cover Sheet Incident Investigation Report Workers’ Compensation Referral Slip for Injured Employees Authorization to Treat Form 1 – Notice of Sub-contract Award Form 2 – Enrollment Form Form 4 – Notice of Anticipated Completion Certificate of Insurance ZURICH CLAIM REPORTING COVER SHEET Email to: XXX_XXXXXXXXXX@XXXXXXXX.XXX OR Fax to: (000) 000-0000 Account Name: Memphis Shelby County Airport OCIP V Master WC policy #: WC 6675835-00 Master GL Policy #: GLO 6675834-00 Project Location: Subcontractor/Employer Policy Number: Contact Name: Contact Phone Number: Contact Fax Number: __ _ __ Location Code: Injured Worker: Attention Zurich Representative – Please fax the receipt and claim number immediately to the contact above. Incident Investigation Report (To be completed within 24 hours by Supervisor at time of incident) INJURED EMPLOYEE INFORMATION 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 UNSAFE ACTS UNSAFE CONDITIONS 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 INJURY/ILLNESS DATA 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 List any eyewitnesses to the incident and others who might provide information about the incident INCIDENT/ILLNESS EVALUATION How did the incident occur? Describe in detail the task the employee was doing when injured or became ill. Include specifics such as equipment, structure tools, materials, objects (size, shape, and weight), people involved in the task, positions, distances, rate of movement, sequence of events, etc. (Attach any additional information comments, documentation of interviews, sketches, pictures, etc. as necessary) Incident Investigation Report Incident/Illness Evaluation (continued) Type of exertion/body motion during injury: Pull Lift Bend Reach Twist Other Was this the employee’s regular job? Yes No How much experience does this employee have on this job? Was the employee trained in this job or task? Yes No When was last training on this task? Was this the employee’s first job-related injury or illness? Yes No If no, briefly describe previous injuries (date, nature, extent, etc.) Hours of overtime worked in last 24 hours Did this possibly contribute to incident? If so, describe Does a safety rule or policy apply to this task? Yes No If yes, describe rule and how employee followed or violated Does a specific procedure for task exist? Yes No If yes, describe procedure briefly and if it was followed Is protective equipment required for this task? Yes No If yes, describe equipment, if it was used, if it was adequate/functioned properly, and if the employee(s) were trained on it. Is there possibly any third party which contributed to the incident? (Other contractors, employee, etc.) Yes No If yes, describe. Did any unsafe physical/environmental conditions exist? Yes No If yes, describe conditions (physical , mechanical, electrical, etc.) which contributed to the incident Is material handling equipment required for this task? Yes No If yes, was it used and did it function properly? Possible actions to be taken to prevent reoccurrence Reinstruction of employee(s) involved Do/revise Job Safety Analysis Repair/replace/modify equipment Preventative instruction of others who do job Revise/establish safety rule Improve clean-up procedure Training of employee(s) Reassign employee to another job Improve inspection procedure Action to improve enforcement Require/replace protective equipment Eliminate/reduce congestion Reprimand/discipline of employee(s) involved Install safety guard device Improve design/construction Improve environmental conditions Possible actions to be taken to prevent reoccurrence CORRECTIVE ACTION(S) TAKEN OR PLANNED What was/will be done By Whom Estimated Completion Date Completion Confirmed Completion Date Date Initial s Incident discussed with employee to prevent reoccurrence? Yes No Date Any disciplinary action taken? Yes No If yes, describe what type. FOLLO W UP COMMUNICATION YES NO Incident site reviewed by supervisor with employee (and safety coordinator if applicable.) YES NO Incident review meeting conducted. Attended by YES NO Employee or supervisor reviewed incident with work group. YES NO Employee reviewed injury with safety committee YES NO Project Safety informed of incident Date of Report Prepared by Title Reviewed by SuperintendentSuperintendent MSCAA OCIP V 0000 Xxxxxxx Xxxx. Memphis, TN, 38116 WORKER’S COMPENSATION REFERRAL SLIP FOR INJURED EMPLOYEES On-Site EMT: (000) 000-0000 Authorized Clinic: Concentra Medical Center 0000 Xxxxxxx Xxxxxxxxx Suite 102 Memphis, TN 38132 (000) 000-0000 (Phone) (000) 000-0000 (Fax) Clinic Hours: 8 a.m. to 8 p.m. (Mon. – Fri.) Authorized After- Methodist South Hospital Hours Clinics: 0000 Xxxxxx Xxxxx Memphis, TN 38116 (000) 000-0000 Baptist Memorial Hospital DeSoto 0000 Xxxxxxxxxx Xxxxxxx Southaven, MS 38671 (000) 000-0000 Employee Name: Date: Employer: Employer Policy Number: Location Code (if known): Claim Number (if known): Account Name: Memphis Shelby County Airport Authority OCIP V Insurer: Zurich Master Policy Number: WC 6675835-00 Instructions for medical facility: The person listed above has been injured on the job. Please provide the employee with medical treatment per OCIP protocol. Local Office Information MSCAA OCIP V Authorization to Treat Billing Information for Drug Screens Address: PO Box 968077 Xxxxxxxxxx, IL 00000-0000 Phone: (000) 000-0000 Fax: (000) 000-0000 Insurance Information for Work Comp Carrier Company Name: Zurich American Insurance Company Master Policy #: WC 0183275-00 Address: PO Box 968077 Xxxxxxxxxx, IL 00000-0000 Phone: (000) 000-0000 Fax: (000) 000-0000 Services Required Worker’s Comp Injuries Drug Screen Required For (employer to check necessary testing): Pre-Employment Random Probable Cause Post Accident Urine (collection only) Breath Alcohol Test Cup (Cocaine, PCP, etc.) Treating Medical Center: Please be advised if negative, DO NOT send out. Be sure to mark on the Chain of Custody (COC) the information for the employer: Employer: Fax: Special Instructions: Use TEST CUP. Do NOT send out unless the test reads positive. Fax results to designated employer listed above. Company Authorized Signature: Date: MSCAA OCIP V Notice of Subcontract Award and Request for Insurance Send this Form to: Xxxxxx Xxxxxx Xxxxxx Phone: (000) 000-0000 Xxxxxx Xxxxx, CSS Email: xxxxxx.xxxxx@xxxxx.xxx Copy: Xxxxx Xxxxxx, CSS Email: xxxxx.xxxxxx@xxxxx.xxx 000 X. Xxxxx St., Suite 4300 Phone: (000) 000-0000 Dallas, TX 75201 RE: Project Name: This is to inform you that we have awarded the following subcontract to the following Subcontractor: Name of Firm: Address: City: State: Zip: Phone: ( ) Fax: ( ) Office Contact: E-Mail: Type of Work: Job # Contract Value: $ Award Date: Estimated Start Date: Awarding Contractor: By: Title: Date: Prime Contractor (if different) DO NOT complete this form for your own company. A Form-1 should be completed on each of your Subcontractors. • Award Date – date Notice to Proceed was given (Verbally or in Writing) • Start date is mandatory – date shown will be the effective date of coverage. Any Contractors or Subcontractors who enrolls in the OCIP 30 days after their start date will have to provide a No Known Loss Letter to the Carrier along with the enrollment documentation. Additional Contract Time & Material Contract Short Term (< 30 days) Small Contract (< $30,000) MSCAA OCIP V ENROLLMENT FORM CONTRACTOR’S INFORMATION Contractor: Indv Ptshp Corp J/V Address: FEIN: Office Contact: Phone: Email: Site Contact: Phone: Email: Safety Contact: Phone: Email: Insurance Contact: Phone: Email: Payroll Contact: Phone: Emai: Address (if different): Job Name/Description: Contract/JOB #: Awarding Contractor: Prime Contractor: Award Date: Start Date: Est Completion Date: Self Performed: %, Est. CV $: Subcontracted _%; Est. CV $: Est. # of Subcontractors Est. Man hours _ _ DBE/MBE/WBE: CURRENT INSURANCE INFORMATION; Contractors’ Insurance Broker or Agent: PLEASE PRINT Company Name: Contact: City/State/Zip: Phone: (_ _) WORKERS’ COMPENSATION Current Experience Modifier: (Provide documentation confirming)

Miscellaneous Claims Notes. 1. Any incident that involved injury to persons or property is to be reported to Xxx Xxxxxx, 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 Xxx Xxxxxx, OCIP Safety Coordinator, prior to coming on the site. There will be no exceptions to this stipulation. ZURICH CLAIM REPORTING COVER SHEET Email to: XXX_XXXXXXXXXX@XXXXXXXX.XXX OR Contact Fax Number: __ _ __ Employee Name Male Femal Date of Birth Ht. Wt. e Employee Address Street City State Xxxxxxxx Xxxxxxx Xxxxxx Xxxx Xxxxx 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? Describe in detail the task the employee was doing when injured or became ill. Include specifics such as equipment, structure tools, materials, objects (size, shape, and weight), people involved in the task, positions, distances, rate of movement, sequence of events, etc. (Attach any additional information comments, documentation of interviews, sketches, pictures, etc. as necessary) Type of exertion/body motion during injury: Pull Lift Bend Reach Twist Other Was this the employee’s regular job? Yes No How much experience does this employee have on this job? Was the employee trained in this job or task? Yes No When was last training on this task? Was this the employee’s first job-related injury or illness? Yes No If no, briefly describe previous injuries (date, nature, extent, etc.) Hours of overtime worked in last 24 hours Did this possibly contribute to incident? If so, describe Does a safety rule or policy apply to this task? Yes No If yes, describe rule and how employee followed or violated Does a specific procedure for task exist? Yes No If yes, describe procedure briefly and if it was followed Is protective equipment required for this task? Yes No If yes, describe equipment, if it was used, if it was adequate/functioned properly, and if the employee(s) were trained on it. Is there possibly any third party which contributed to the incident? (Other contractors, employee, etc.) Yes No If yes, describe. Did any unsafe physical/environmental conditions exist? Yes No If yes, describe conditions (physical , mechanical, electrical, etc.) which contributed to the incident Is material handling equipment required for this task? Yes No If yes, was it used and did it function Reinstruction of employee(s) involved Do/revise Job Safety Analysis Repair/replace/modify equipment Preventative instruction of others who do job Revise/establish safety rule Improve clean-up procedure Training of employee(s) Reassign employee properly? Possible actions to another job Improve inspection procedure Action be taken to improve enforcement Require/replace protective equipment Eliminate/reduce congestion prevent reoccurrence Reprimand/discipline of employee(s) involved Install safety guard device Improve design/construction Improve environmental conditions Possible actions to be taken to prevent reoccurrence CORRECTIVE ACTION(S) TAKEN OR PLANNED What was/will be done By Whom Estimated Completion Date Completion Confirmed Completion Date Date Initial s Incident discussed with employee to prevent reoccurrence? Yes No Date Any disciplinary action taken? Yes No If yes, describe what type. YES NO Incident site reviewed by supervisor with employee (and safety coordinator if applicable.) YES NO Incident review meeting conducted. Attended by YES NO Employee or supervisor reviewed incident with work group. YES NO Employee reviewed injury with safety committee YES NO Project Safety informed of incident Date of Report Prepared by Title Reviewed by Superintendent

Miscellaneous Claims Notes. 1. Any incident that involved injury to persons or property is to be reported to Xxx Xxxxxx, 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 Xxx Xxxxxx, OCIP Safety Coordinator, prior to coming on the site. There will be no exceptions to this stipulation. ZURICH CLAIM REPORTING COVER SHEET Email to: XXX_XXXXXXXXXX@XXXXXXXX.XXX OR Contact Fax Number: __ _ __ Incident Investigation Report (To be completed within 24 hours by Supervisor at time of incident) 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? Describe in detail the task the employee was doing when injured or became ill. Include specifics such as equipment, structure tools, materials, objects (size, shape, and weight), people involved in the task, positions, distances, rate of movement, sequence of events, etc. (Attach any additional information comments, documentation of interviews, sketches, pictures, etc. as necessary) Type of exertion/body motion during injury: Pull Lift Bend Reach Twist Other Was this the employee’s regular job? Yes No How much experience does this employee have on this job? Was the employee trained in this job or task? Yes No When was last training on this task? Was this the employee’s first job-related injury or illness? Yes No If no, briefly describe previous injuries (date, nature, extent, etc.) Hours of overtime worked in last 24 hours Did this possibly contribute to incident? If so, describe Does a safety rule or policy apply to this task? Yes No If yes, describe rule and how employee followed or violated Does a specific procedure for task exist? Yes No If yes, describe procedure briefly and if it was followed Is protective equipment required for this task? Yes No If yes, describe equipment, if it was used, if it was adequate/functioned properly, and if the employee(s) were trained on it. Is there possibly any third party which contributed to the incident? (Other contractors, employee, etc.) Yes No If yes, describe. Did any unsafe physical/environmental conditions exist? Yes No If yes, describe conditions (physical , mechanical, electrical, etc.) which contributed to the incident Is material handling equipment required for this task? Yes No If yes, was it used and did it function Reinstruction of employee(s) involved Do/revise Job Safety Analysis Repair/replace/modify equipment Preventative instruction of others who do job Revise/establish safety rule Improve clean-up procedure Training of employee(s) Reassign employee to another job Improve inspection procedure Action to improve enforcement Require/replace protective equipment Eliminate/reduce congestion Reprimand/discipline of employee(s) involved Install safety guard device Improve design/construction Improve environmental conditions Possible actions to be taken to prevent reoccurrence CORRECTIVE ACTION(S) TAKEN OR PLANNED What was/will be done By Whom Estimated Completion Confirmed Completion Date Date Initial s Incident discussed with employee to prevent reoccurrence? Yes No Date Any disciplinary action taken? Yes No If yes, describe what type. YES NO Incident site reviewed by supervisor with employee (and safety coordinator if applicable.) YES NO Incident review meeting conducted. Attended by YES NO Employee or supervisor reviewed incident with work group. YES NO Employee reviewed injury with safety committee YES NO Project Safety informed of incident Date of Report Prepared by Title Reviewed by Superintendent

Miscellaneous Claims Notes. 1. Any incident that involved injury to persons or property is to be reported to Xxx Xxxxxx, 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 Xxx Xxxxxx, OCIP Safety Coordinator, prior to coming on the site. There will be no exceptions to this stipulation. ZURICH CLAIM REPORTING COVER SHEET Email to: XXX_XXXXXXXXXX@XXXXXXXX.XXX 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? Describe in detail the task the employee was doing when injured or became ill. Include specifics such as equipment, structure tools, materials, objects (size, shape, and weight), people involved in the task, positions, distances, rate of movement, sequence of events, etc. (Attach any additional information comments, documentation of interviews, sketches, pictures, etc. as necessary) Type of exertion/body motion during injury: Pull Lift Bend Reach Twist Other Was this the employee’s regular job? Yes No How much experience does this employee have on this job? Was the employee trained in this job or task? Yes No When was last training on this task? Was this the employee’s first job-related injury or illness? Yes No If no, briefly describe previous injuries (date, nature, extent, etc.) Hours of overtime worked in last 24 hours Did this possibly contribute to incident? If so, describe Does a safety rule or policy apply to this task? Yes No If yes, describe rule and how employee followed or violated Does a specific procedure for task exist? Yes No If yes, describe procedure briefly and if it was followed Is protective equipment required for this task? Yes No If yes, describe equipment, if it was used, if it was adequate/functioned properly, and if the employee(s) were trained on it. Is there possibly any third party which contributed to the incident? (Other contractors, employee, etc.) Yes No If yes, describe. Did any unsafe physical/environmental conditions exist? Yes No If yes, describe conditions (physical , mechanical, electrical, etc.) which contributed to the incident Is material handling equipment required for this task? Yes No If yes, was it used and did it function Reinstruction of employee(s) involved Do/revise Job Safety Analysis Repair/replace/modify equipment Preventative instruction of others who do job Revise/establish safety rule Improve clean-up procedure Training of employee(s) Reassign employee to another job Improve inspection procedure Action to improve enforcement Require/replace protective equipment Eliminate/reduce congestion Reprimand/discipline of employee(s) involved Require/replace protective equipment Install safety guard device Eliminate/reduce congestion Improve design/construction Improve environmental conditions Possible actions to be taken to prevent reoccurrence CORRECTIVE ACTION(S) TAKEN OR PLANNED What was/will be done By Whom Estimated Completion Confirmed Completion Date Date Initial s Incident discussed with employee to prevent reoccurrence? Yes No Date Any disciplinary action taken? Yes No If yes, describe what type. YES NO Incident site reviewed by supervisor with employee (and safety coordinator if applicable.) YES NO Incident review meeting conducted. Attended by YES NO Employee or supervisor reviewed incident with work group. YES NO Employee reviewed injury with safety committee YES NO Project Safety informed of incident Date of Report Prepared by Title Signature Reviewed by Superintendent

Miscellaneous Claims Notes. 1. Any incident that involved injury to persons or property is to be reported to Xxx Xxxxxx, 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 Xxx Xxxxxx, OCIP Safety Coordinator, prior to coming on the site. There will be no exceptions to this stipulation. Zurich Claim Reporting Cover Sheet Incident Investigation Report‌ Workers’ Compensation Referral Slip for Injured Employees Authorization to Treat‌ Form 1 – Notice of Sub-contract Award Form 2 – Enrollment Form‌ Form 4 – Notice of Anticipated Completion Certificate of Insurance‌ ZURICH CLAIM REPORTING COVER SHEET Email to: XXX_XXXXXXXXXX@XXXXXXXX.XXX OR Contact Fax Number: __ _ __ Employee Name Male Femal Date of Birth Ht. Wt. e Employee Address Street City State Xxxxxxxx Xxxxxxx Xxxxxx Xxxx Xxxxx 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? Describe in detail the task the employee was doing when injured or became ill. Include specifics such as equipment, structure tools, materials, objects (size, shape, and weight), people involved in the task, positions, distances, rate of movement, sequence of events, etc. (Attach any additional information comments, documentation of interviews, sketches, pictures, etc. as necessary) Type of exertion/body motion during injury: Pull Lift Bend Reach Twist Other Was this the employee’s regular job? Yes No How much experience does this employee have on this job? Was the employee trained in this job or task? Yes No When was last training on this task? Was this the employee’s first job-related injury or illness? Yes No If no, briefly describe previous injuries (date, nature, extent, etc.) Hours of overtime worked in last 24 hours Did this possibly contribute to incident? If so, describe Does a safety rule or policy apply to this task? Yes No If yes, describe rule and how employee followed or violated Does a specific procedure for task exist? Yes No If yes, describe procedure briefly and if it was followed Is protective equipment required for this task? Yes No If yes, describe equipment, if it was used, if it was adequate/functioned properly, and if the employee(s) were trained on it. Is there possibly any third party which contributed to the incident? (Other contractors, employee, etc.) Yes No If yes, describe. Did any unsafe physical/environmental conditions exist? Yes No If yes, describe conditions (physical , mechanical, electrical, etc.) which contributed to the incident Is material handling equipment required for this task? Yes No If yes, was it used and did it function properly? Possible actions to be taken to prevent reoccurrence Reinstruction of employee(s) involved Do/revise Job Safety Analysis Repair/replace/modify equipment Preventative instruction of others who do job Revise/establish safety rule Improve clean-up procedure Training of employee(s) Reassign employee to another job Improve inspection procedure Action to improve enforcement Require/replace protective equipment Eliminate/reduce congestion Reprimand/discipline of employee(s) involved Require/replace protective equipment Install safety guard device Eliminate/reduce congestion Improve design/construction Improve environmental conditions Possible actions to be taken to prevent reoccurrence CORRECTIVE ACTION(S) TAKEN OR PLANNED What was/will be done By Whom Estimated Completion Confirmed Completion Date Date Initial s Incident discussed with employee to prevent reoccurrence? Yes No Date Any disciplinary action taken? Yes No If yes, describe what type. YES NO Incident site reviewed by supervisor with employee (and safety coordinator if applicable.) YES NO Incident review meeting conducted. Attended by YES NO Employee or supervisor reviewed incident with work group. YES NO Employee reviewed injury with safety committee YES NO Project Safety informed of incident Date of Report Prepared by Title Reviewed by Superintendent