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Report An Accident

    Please Fill Out This Form. If you need to call, please call 570-550-2978

    DETAILS OF THE PERSON IN ACCIDENT

    CONTACT INFORMATION



    ACCIDENT CLASSIFICATION


    ACCIDENT DETAILS

    Date of Accident




    Have all IBEW locals been notified:

    YESNONOT SURE

    FAMILY MEMBERS WE MAY CONTACT







    ADDITIONAL INFORMATION

    SUBMISSION DETAILS


    Date Submitted: