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[{
"GeneralLiabilityIncidentDetails": {
"IncidentDetails": {
"IncidentInternalID": "sample string",
"IncidentIDSystemGenerated": "sample string",
"IncidentTitleSite": "sample string",
"IncidentType": "sample string",
"LocationCode": "sample string",
"Location": "sample string"
},
"GeneralDetails": {
"WouldyouliketosubmitaGeneralLiabilityClaim": "sample string",
"GeneralLiabilityType": "sample string",
"Sub-incidentType": "sample string",
"DateOfIncident": "2022-10-04T00:00:00.000Z",
"TimeOfIncident": "12:25",
"TimeUndetermined": "sample string",
"DayOfWeek": "sample string",
"WorkShift": "sample string",
"TimeWorkDayBegan": "sample string",
"DescriptionofIncident": "sample string",
"DateReportedtoEmployer": "2022-10-27T00:00:00.000Z",
"TimeReportedtoEmployer": "-",
"WasAssetinvolved": "sample string",
"Assets": [{
"sample string 2"
}],
"Significance": "sample string"
},
"PersonDetails": [{
"Wereindividualsinvolvedintheincident": "sample string",
"Numberofinvolvedindividuals": "sample string",
"Name": "sample string",
"Gender": "sample string",
"DateOfBirth": "sample string",
"HomeAddress": "sample string",
"City": "sample string",
"State": "sample string",
"Zip": "sample string",
"PhoneNumber": "sample string",
"Whatwaspersondoingbeforeincident": "sample string",
"Wasindividualinjuredintheincident": "sample string",
"DidInjuryresultinaFatality": "sample string",
"ResultofIncident": "sample string",
"CauseofIncident": "sample string",
"InjuredBodyPart": "sample string",
"Pleasedescribepersonsinjury": "sample string",
"Waspersonconsideredminor": "sample string",
"Pleaseprovideparentsname": "sample string",
"Pleaseprovideparentsphonenumber": "sample string",
"Takenfromsceneviaambulance": "sample string",
"Whatshoeswasclaimantwearing": "sample string",
"Wasclaimantstruckbyobject": "sample string",
"Ifstruckbyobjectwhatobject": "sample string",
"Didthepersonrefusetreatment": "sample string",
"IfYesexplainwhy": "sample string",
"Wastreatmentprovided": "sample string",
"DidthepersonsignthemedicalreleaseformIfyespleaseattach": "sample string",
"WereEmergencyServicescalled?": "sample string",
}],
"EmployeeDetails": {
"PersonnelType": "sample string",
"EmployeeInvolved": "sample string",
"EmployeeId": "sample string",
"PayRateType": "sample string",
"EmployeeDepartment": "sample string",
"Contractor": "sample string",
"DoyouwanttoclassifyUnsupervisedContractEmployee": "sample string",
"TypeofClientPersonnel": "sample string",
"ClientCompany": "sample string",
"NameofContractor": "sample string",
"NameofSubContractor": "sample string"
},
"LocationOfIncident": {
"IncidentOccurredonEmployersPremises": "sample string",
"AddressofIncidentLocation": "sample string",
"City": "sample string",
"County": "sample string",
"State": "sample string",
"Zip": "sample string",
"Department": "sample string",
"PinLocation": "sample string",
"LocationoftheIncident": "sample string",
"StoreManagerName ": "sample string",
"StoreManagerPhone": "sample string",
"DistrictManagerName": "sample string",
"DistrictManagerPhone": "sample string",
"Wasanythingonfloor": "sample string",
"Floorgroundscondition": "sample string",
"Incidentoccurinsideoutside": "sample string",
"IfInsidestorewhere": "sample string",
"IfInsidestorecause": "sample string",
"IfinStockroomwhere": "sample string",
"IfOutsidestorewhere": "sample string",
"IfOutsidestorecause": "sample string",
"Istherevideooftheincident": "sample string",
"Ifvideonotobtainedwhy": "sample string",
"IfEquipnotfunctionalWhy": "sample string",
"Didtheincidentresultinanydamagetocompanyequipment": "sample string",
"Pleasedescribeequipmentanddamage": "sample string",
"Didtheincidentresultinanystructuraldamage": "sample string",
"Pleasedescribedamage": "sample string",
"Wastheincidentaresultoftheftorasecurityrelatedactivity": "sample string",
"Pleasedescribetheftorsecurityrelatedincident": "sample string",
"Isthisanassaultorrobbery": "sample string",
"Weretheresuspects": "sample string",
"Werearrestsmade": "sample string",
"Wasthereapolicereport": "sample string",
"LossPreventionreport": "sample string",
"Askthemtotakephotographs": "sample string",
"Incidentlocationdiagrammade": "sample string",
},
"ProductLiability": {
"IsthisclaimaProductLiabilityclaim": "Yes",
"ProvideNameofProduct": "sample string",
"ProvideProductCode": "sample string",
"ManufacturersName": "sample string",
"ManufacturerAddress1": "sample string",
"ManufacturerAddress2": "sample string",
"ManufacturerCity": "sample string",
"ManufacturerState": "sample string",
"ManufacturerPostalCode": "sample string",
"ManufacturerPhone": "sample string",
"Pleaseprovideadetaildescriptionoftheproduct": "sample string",
"Wasstoreadvisedtoretaintheproduct": "sample string",
"Isstoreincurrentpossessionofproduct": "sample string",
"Briefdescriptionoffactsofloss": "sample string",
"Responsibilityforroatingproduct": "sample string",
"Didalocalvendorprovidethisproduct": "sample string",
"VendorsName": "sample string",
"VendorsPhoneNumber": "sample string"
},
"MedicalInformation": {
"WasindividualsenttoHospitalClinictoreceivemedicaltreatment": "yes",
"HospitalClinicName": "sample string",
"Address": "sample string",
"City": "sample string",
"State": "sample string",
"Zip": "sample string",
"PhoneNumber": "sample string",
"Fax": "sample string",
"ClinicDoctorName": "sample string"
},
"WitnessInformation": [{
"ArethereanyWitnessesIdentified": "Yes",
"NumberofWitnesses": 1,
"LastName": "sample string",
"FirstName": "sample string",
"MiddleName": "sample string",
"PhoneNumber": "sample string",
"Notes": "sample string"
}],
"ReportInformation": {
"ReportedBy": "sample string",
"Title": "sample string",
"PhoneNumber": "sample string",
"EmailAddress": "sample string"
},
"AdditionalIncidentInformation": {
"IncidentStatus": "sample string",
"CreatedBy": "sample string",
"CreatedDate": "2022-10-27T08:24:50.940Z",
"LastUpdatedBy": "sample string",
"LastUpdatedDate": "2022-10-27T08:24:50.940Z"
}
},
"InvestigationReport": {
"InvestigationResponsibility": {
"ResponsibleTeam": [{
"Salutation": "sample string",
"FirstName": "sample string",
"LastName": "sample string"
}],
"TargetCompletionDate": "2020-04-30T00:00:00.000Z",
"Note": null,
"NotifyImmediateSupervisor": "Y"
},
"InvestigationDetails": [],
"ContributingFactors": [{
"ContributingFactorType": "sample string",
"ContributingFactors":
[
"sample string"
],
"Comments": "sample string"
}],
"5WhyMethodology": [{
"SelectActionorConditionthatmayhavedirectlycausedincident":
[
"Computer Theft"
],
"5Whys": []
}],
"RootCauseStatement": [{
"RootcauseType": "sample string",
"RootCause":
[
"sample string"
],
"Comments": "sample string"
}],
"FinalRootCauseStatement": [{
"FinalRootCauseStatement": "sample string",
"PrimaryCountermeasure": "sample string",
"PrimaryRootCause": "sample string"
}]
},
"ActionItems": [{
"SourceID": "sample string",
"SourceTitle": "sample string",
"ActionItemTitle": "sample string",
"ActionItemCategory": "sample string",
"ActionItemType": "sample string",
"ActionItemDescription": "sample string",
"ActionItemPriority": "sample string",
"ActionItemDueDate": "2020-04-16T00:00:00.000Z",
"Owners": [
"sample string"
],
"ResponsibleDepartment": "sample string",
"CounterMeasure": "sample string",
"ApplicabletoExpansion": "sample string",
"DescriptionofActionstobeExpanded": "sample string",
"ApplicabletoEEMEPMInfo": "sample string",
"EEMEPM": "sample string",
"EEMEPMInfoSubmitted": "sample string",
"DocumentNumber": "sample string",
"AssignedBy": "sample string",
"VerificationRequired": "sample string",
"ActionItemStatus": "sample string",
"ActionTaken": "sample string",
"ActionItemCompletedBy": "sample string",
"CompletedDate": null,
"DueDateExtension": "sample string",
"RequestedDueDateExtension": null,
"ReasonforDueDateExtension": "sample string",
"DueDateExtensionRequestApproved?": "sample string",
"ReasonfornotextendingtheDueDate": "sample string"
}],
"ManagementReview": [
{
"RoleName": "sample string",
"Owner":
[
"sample string"
],
"approvalduedate": "2020-04-30T00:00:00.000Z",
"Comments": "sample string",
"CompletedByManagementReview": "sample string",
"CompletedDate": ""
},
{
"ManagementReviewStatus": "sample string"
}
]
}] |
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