Hazard Reporting Form


 

 

Use this form as an alternate to calling the Hazard Hot Line 703-324-HZRD (703-324-4973).

Complete and submit this form and a member of the Loss Prevention team will investigate and mitigate any safety related issues. See a Hazard, Stop an Injury.

Required fields are denoted with red asterisk * .

* Incident date:     Pick Event Date

* Incident Category:   Incident   Near Miss/Close Call

Incident Location complete as much as possible:  
* Address 1:   
   Address 2:   

Suite/Room Number:   

* City:   

Incident Factors(limit 400 characters): 

Contact Information (optional):

Contact Name:   

Telephone Number:  xxx-xxx-xxxx include area code 

E-mail Address:   

* Is this related to a claim?  Yes   No

If this is related to a claim, is it:

   Sprain/strain
   Slip/trip/fall
   Laceration
   Bite/sting
   Fracture
   Other


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