Miejscowość ..................................................., dnia ................................
UZYSKANE OD POSZKODOWANEGO
w wypadku przy pracy, zrównanym z wypadkiem przy pracy, przy wykonywaniu umowy agencyjnej lub umowy zlecenia*, któremu
uległ(a) w dniu .......................................... o godz. ........................ Pan(i) .......................................................................................................................................
(nazwisko i imię poszkodowanego)
POSZKODOWANY(A):
Nazwisko i imię ...................................................................................................................................... Imię ojca ............................................................................
Data i miejsce urodzenia ..........................................................................................................................................................................................................................
Miejsce zamieszkania ...............................................................................................................................................................................................................................
Zatrudniony(a) .................................................................................................................................. Staż pracy w obecnym zakładzie pracy .......................
(dział, wydział)
Stanowisko .................................................................................................................................................................... Staż pracy na stanowisku .......................
(nazwa)
Zespół powypadkowy w składzie:
1. .............................................................................................................................................................................................................................................. Członek
(nazwisko i imię) (stanowisko)
2. .............................................................................................................................................................................................................................................. Członek
Poszkodowany wyjaśnia co następuje:
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*) niepotrzebne skreślić - verte-
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Na tym zakończono i po osobistym odczytaniu, jako zgodne z moimi wyjaśnieniami podpisuję:
....................................................................................... 1. ...........................................................................................
(podpis poszkodowanego)
2. .............................................................................................
(podpisy zespołu powypadkowego)
str. 1
gienekd