MCA Initial Incident Reporting Form
Must be completed and reported to the MCA HR Manager within 48 hours of the incident occuring.

Allianz First Report: Phone 1300 360 595
MCA Policy Number: MWF0011682

Name of person reporting
Your answer
Date and time of the incident
Please be as accurate as possible
MM
/
DD
/
YYYY
Time
:
Casualty Full Name
Your answer
Casualty Contact Number
Your answer
Details of the Incident AND Injury Sustained
Please provide as much detail as possible including where the injury happened and what part of the body was injured.
Your answer
Treatment Provided
Provide details of the treatment given
Your answer
What action was taken?
What steps were put in place to prevent a recurrence?
Your answer
Submit
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