A near miss is a potential hazard or incident that has not resulted in any personal injury. Unsafe working conditions,
unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to
cause work related injuries. It is everyone’s responsibility to report and /or correct these potential accidents/incidents
immediately. Please complete this form as a means to report these near-miss situations.
Near Miss Reporting Form
Your Near Miss Form has been successfully submitted.
Please be advised
You are NOT reporting a claim by submitting this near-miss report. If you
need to submit an actual claim, please contact our claims department at
800-356-8360, or log in to report your claim online.