Maritime Claim
Name:
*
Email:
*
Phone:
Mailing Address:
Who is/was your employer at the time of the injury:
Describe your injury:
Date of injury:
Date you reported injury:
Who did you report the incident to:
Did you fill out the Incident Report, or did someone fill it out for you:
You
Someone Else
Did you receive a copy of the Incident Report:
Yes
No:
Was your Incident Report electronically filled out:
Yes
No
Have you seen a doctor:
Yes
No
What date did you see the doctor:
Did you see the doctor immediately after getting off the vessel:
Yes
No
Did you drive yourself to the doctor:
Yes
No
Did a crewmember of fellow employee drive you to the doctor:
Yes
No
Was the doctor a compnay doctor:
Yes
No
Please provide the doctor's name and telephone number:
Are the boat logs kept electronic or handwritten:
Electronic
Handwritten
Where were you on the river or inland water way when the incident occurred:
River
Inland
Is there a mile marker or dock:
Mile Marker
Dock
Neither
Who witnessed the injury:
What could your employer have done differently to prevent the incident:
Were there other previous incidents like yours:
Yes
No
Were there complaints, prior to your incident, of the problem that needed to be fixed that caused your incident:
Yes
No
What were you towing at the time of the incident:
Were you on the tug, barge or other vessel:
How long had you been on your hitch at the time of the incident:
Name of Captain:
Name of First Mate:
Name of Second Mate:
Other crew members:
Date of employment:
Every been injured before:
Yes
No
File IRS and State taxes every year you are required to:
Convicted of a crime:
Yes
No
Have you ever been arrested:
Yes
No
Are you married:
If married, spouse's name:
Children, if yes, please list names and ages: