Sample Letter that Shows How to Write an Incident Report When a Workplace Accident Causes Personal Injury
Use the Initial Incident Report for Work to Explain How the Workplace Accident Occurred and Protect Your Right to Workers Compensation
Providing timely written notice of the accident to your employer (often 30 days or less) is the first step in the workers compensation claim process.
A missed deadline or an insufficient incident report letter that omits necessary details may cause you to lose your case and lower the potential value of a workers compensation settlement payout.
This article provides a sample workplace accident report you can use as a template for the letter you give the employer explaining how the incident happened.
You can use all or part of this sample letter reporting a workplace injury to write an incident report specific to your case and state’s requirements.
After you review this sample accident report, you can read the rest of my website for answers to your frequently asked questions (FAQs) about workers comp in Virginia.
Then, fill out this form or call (804) 251-1620 or (757) 810-5614 for help with your claim. We have helped thousands of injured employees win claims in Virginia or find skilled attorneys in states we do not practice. Let’s see if we can assist you.
What is a Workplace Accident Report?
The workplace accident report is a written document explaining the details of a work-connected accident, injury, or illness.
Why Do I Need to Write a Workplace Incident Report?
The work incident report has multiple purposes.
For example, a detailed letter explaining how the workplace accident occurred and documenting the notice you gave and treatment received can help you qualify for workers compensation benefits like temporary total disability (TTD) payments and lifetime medical coverage.
In addition, this letter notifying the employer of an occupational injury or illness triggers specific employers’ responsibilities under workers compensation law.
Further, your work incident report helps the employer comply with other labor and employment laws (such as the Occupational Safety Act) and fix unsafe work conditions so your coworkers avoid harm.
What Information Should I Include in the Workplace Accident Report?
A lot of contradictory information exists on how to write an incident report.
On the one hand, the workplace accident report should be comprehensive, including all the critical details in one place.
On the other hand, writing the letter reporting the injury without knowing what workers comp does or does not cover may lead you to include irrelevant information that leads the insurer to delay or deny your claim.
Generally, the incident report explaining the workplace accident should include the following:
-
- Your name and contact information
- Contact information for your next of kin or someone you trust to give and receive information about the work-connected injury
- Your attorney’s contact information if you have retained legal counsel
- When the incident happened
- Where the incident happened
- How the accident happened
- Why you think the injury happened (inadequate safety training, debris, defective machinery, etc.)
- Your initial symptoms (feeling a pop, pain, etc.)
- Witnesses to the incident
- Who you have told about the incident
- Where you received medical treatment
- Your understanding of the body parts injured
- Your ongoing symptoms
- What problems you would have performing your job due to these symptoms
- Your upcoming medical appointments
I also recommend avoiding specific items in the incident report.
For example, do not call other people names or use vulgar language, even if you think a coworker or supervisor ignored your safety concerns or made a mistake that led to the injury.
Should I Attach Anything to the Workplace Accident Report?
Yes.
Attach any photographs or videos of your injuries (such as bruising, bleeding, or a cut) or the accident scene.
In addition, I recommend providing medical records, work restriction notes, and signed witness statements supporting your events.
Sample Letter – Workplace Accident Report
I have told you what to include in the incident report. Now I will show you what details to include.
Check out the below example of a workplace accident report letter. Any references to real people and telephone numbers are incidental.
Sent by Certified Letter and Email
Bill Thomas
Supervisor and Safety Director
Jim’s Trucking Company
100 Truckstop Lane
Richmond, VA 23236
Email:bigbill@jimstrucking.com
July 5, 2024
Dear Mr. Thomas:
This letter is written notice that I suffered injuries in a work-related accident on July 1, 2024, at 7:30 pm.
An Amazon delivery van crashed into my tractor-trailer on Interstate 64 near Exit 263 (Route 258/Mercury Boulevard) in Hampton, VA. A passerby called 911, and a Virginia State Trooper arrived and completed a police crash report. I have not received a copy yet.
The passerby, Cynthia Bagley, witnessed the collision. Her telephone number is 757-001-1000.
The state trooper, John Davis, can be reached at 757-010-0001.
An ambulance took me to Riverside Regional Medical Center in Newport News, VA, where the emergency room doctor diagnosed injuries to my back, shoulder, and knee. I will request copies of my medical reports and send these papers to you soon.
I have a follow-up appointment with an orthopedic surgeon next week and should learn more about the extent of my injuries.
In the meantime, the emergency room doctor disabled me from all work. I will let you know if the orthopedic doctor keeps these restrictions or releases me to light duty. Please let me know if you can provide light duty if so.
While at the hospital, I called Megan Yates, our dispatcher, and told her what happened. She said she would call you immediately and ask what steps I should take next, but I wanted to send this incident report anyway.
Please let me know if I should report this accident and injuries to anyone else or if the company prefers I see a different orthopedic surgeon. If so, could you send me a list of doctors to choose from?
Also, please tell me who our workers compensation insurance carrier is and how to contact them. The law requires that I file a workers’ compensation claim, and I want to do that as soon as possible.
I would also appreciate it if you sent me a copy of any reports or forms you have already completed because of this workplace accident.
Thanks for your assistance. If you need any information from me or wish to speak with me about the accident, my injuries, and my restrictions, call me. You can also talk to my wife, Jessica (757-000-0000), as the pain medication makes me drowsy and unable to talk on the phone for long. She helped me with this letter.
I look forward to healing and getting back to work.
Sincerely,
Alex Adams
757-757-7577
Email:alexadams@jimstrucking.com
What Should I Do With the Letter After I Submit the Workplace Incident Report?
Remember, protecting your rights if you have to litigate the workers comp claim or file a personal injury lawsuit is the primary reason for submitting a workplace accident report.
Therefore, you should take extra steps to prove you completed this report.
I recommend keeping at least two copies of the incident report letter with attachments. In addition, if you send the letter by certified mail or email, you will have written confirmation that the employer received the letter.
We Help Injured and Ill Employees Document Their Accidents and Injuries So They Can Receive Workers Compensation
Workers comp claims involve a lot of paperwork.
You can track what workplace accident reports, medical evidence, and other documents you need to win, all while suffering from the effects of your injuries. Or, you can let us take care of it.
Call now for comprehensive support, including help writing the letter reporting your work injury to the employer and much more. We’re here to ensure you’re not alone in this process.
- Will the Dollar Tree Store Closures Affect My Workers’ Compensation? - March 14, 2024
- SSA Proposes a Rule Change to Work History Evaluation - November 1, 2023
- VA Workers Comp Lawyer: We Win Work Injury Claims - May 8, 2017
