Weight Watchers Incident Report
For Incidents involving WW Vehicles, call Travelers at 1-800-832-7839. No Incident Report is required.
This Report should be completed by a Weight Watchers employee and signed and submitted by a TM or DM for all incidents involving injury to an employee, injury or property damage to a member or visitor or damage to WW’s property (excluding vehicles).
Your Name (Name of WW employee completing form):
Your TM’s or DM’s Name:
Your TM’s or DM’s Phone Number:
Your TM’s or DM’s E-mail Address:
Location Code and Address where the Incident occurred:
Date and Approximate Time the Incident occurred:
If more than one person was injured in this incident, mark “Yes” and complete a separate Incident Report for each person injured. Yes No
If the incident involved an injury to a Weight Watchers employee, please complete Section I of this Report.
If the incident involved an injury to a member or visitor or damage to their property, please complete Section II of this Report.
If the incident involved damage to Weight Watchers property, please complete Section III of this Report. If you have sustained damage to the physical location of a Weight Watchers store or satellite location (NOT A TRADITIONAL TRAVELER WHERE WE ARE IN SOMEONE ELSES PROPERTY), you should also contact FMS at 888-775-5800 and advise of the damage and the need for repairs.
Section I –Employee Injury
This form must be signed and submitted by the Territory Manager (or by the District Manager if the injured employee is a Territory Manager)
WORKERS’ COMPENSATION REPORT FORM
Injured Employee’s Name:
Did the incident occur on the premises? Yes No
If No, Where did the Incident Occur?
Date Incident was reported to You:
Brief Description of Incident:
Which Part(s) of the Body was injured? (e.g., Head, Neck, Right Arm, Left Leg)?
Has the Injured Employee Missed Work As A Result of this Injury? Yes No
If Yes, Date Last Worked:
Has the Injured Employee Returned to Work? Yes No
If Yes, Date Returned to Work:
Employee Address:
Employee Phone Number:
Employee Mailing Address (if different than above):
Male Female Marital Status S M
Date of Birth: Social Security Number:
Occupation:
Date Hired: Years Employed:
Employment Status: FT PT
Was the Injured Employee Sent Offsite for Treatment? Yes No
If Yes, Clinic/Physician – Name, Address:
If Yes, Hospital - Name, Address:
Territory Manager or District Manager’s Signature:
Additional Comments & Information
For incidents in OH, ND, WA and WY, please use the following reporting instructions. You do not have to report the incident to Travelers.
· OH: https://www.ohiobwc.com/bwccommon/forms/froi/default.asp
· ND: https://www.workforcesafety.com/workers/onlineservices.asp
· WA: http://www.lni.wa.gov/ClaimsIns/Insurance/Injury/Default.asp
· WY: Phone: 307-777-7159
Fax: 307-777-6552
ALL OTHER STATES REPORT YOUR CLAIM BY TELEPHONE:
1-800-832-7839
REPORT YOUR CLAIM BY FAX:
1-877-784-5329
REPORT YOUR CLAIM BY Email:
Policy: TC2O-UB-1108L146-13 (All other States)
Policy: TRK-UB-1108L380-13 (for MA and WI)Online: https://clclaimreporting.travelers.com/clrpt/logonagent.asp
Please keep a copy of this form for your records
Section II – Member or Visitor Incident
This form must be signed and submitted by the Territory Manager
WEIGHT WATCHERS CONFIDENTIAL REPORT OF INCIDENT FORM
Risk Management/Q.M. Confidential Report of Event. DO NOT PHOTOCOPY
PRIVILEGED & CONFIDENTIAL REPORT FOR USE BY LEGAL COUNSEL AND RM/QM ACTIVITIES
Did the incident occur on WW Premises: Yes No
INCIDENT INFORMATION:
Incident Involves: Member Visitor
First Name Last Name
Date of Birth:
Gender: Male Female
Street Address:
City: State Zip Code
Phone #:
INCIDENT DESCRIPTION
Provide full description of Incident:
Type & Extent of Injury known:
Was injured person sent for medical treatment? Yes No
If yes, where?
Did the injured person make any statements at the time of incident: Yes No
If yes, what was said?
Were Police called to scene? Yes No If yes, what precinct (if known)
Were there any Witnesses: Yes No If yes, provide contact information for the witnesses:
Signature of Territory Manager:
Date:
Service Provider Reporting Instructions: Send this report to your Territory Manager Reporting Instructions: All member or visitor incidents should be reported within 24 hours to Weight Watchers International c/o Kerry Maurer and Fax to 562-492-1865
Section III– Damage to Weight Watchers Property
This form must be signed and submitted by the Territory Manager
Description of Loss:
Probable Cause of Loss:
Description of Property Damage:
Estimated Cost of Property Damage:
Territory Manager or District Manager’s Signature:
TM Reporting Instructions: E-mail this form to