Incident Report

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Please provide as much accurate, detailed information as possible!
Your information


Best phone number to contact you



Incident Details


Only select "Yes" if you are 100% sure this claim has no monetary impact. A Matter of Record is just an "FYI" and not a full/real claim. All normal/typical claims are not Matters of Record. 

A Near Miss is a potentially dangerous situation. A serious incident did not occur but could have.



















Name of Homeowner, our employee, utility company, etc.



Please list any witnesses to the incident and their relationship to the company. (Customer, employee, subcontractor, etc.)

 

Employee Profile









The operations employee that will work with Risk Department to resolve claim.


Subcontractor Company Details








Auto Details




Please describe the incident



Enter Vehicle Info Manually for Rentals






QualTek Vehicle not found in database:








Vehicle Search by License Plate

Read Only





Vehicle Search by VIN

Read Only







Please attach one photo. There will be space for more at the end of the form.


Photo of other party's insurance information.








There will be space for additional photos at the end of this form

If you do not know, put unknown.













There will be space at the end of the form for additional photos.





Workers Compensation Details















Theft

Please list and describe stolen items




Vehicle not found in database:







Edit section title

Vehicle Search by License Plate

Read Only





Vehicle Search by VIN

Read Only





Property Damage

Please describe in detail the damaged item(s)

Please attach photos of the damage.

Please attach photos of the damage.

Please attach photos of the damage.

Customer's Information


Last Name, First Name




Utility Damage

Hold control to select multiple.


Please indicate the locate company name or state of our company performed the locates.





Third Party Injury

Please provide the injured party's contact information




Near Miss

Please provide as much detail, description and information as possible!






Attachments















Root Cause Analysis and Remediation

Define what caused this incident. Utilize the 5 Why tool to better determine the true root cause.

Define the impact of this incident on all stakeholders.

Detail steps to be implemented to mitigate a recurrence of this incident.

Summarize lessons learned and the communication plan to other stakeholders.





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Contact Information