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NSITF Accident Notification Form

This document contains a notification form from the Nigeria Social Insurance Trust Fund (NSITF) regarding an accident, occupational disease, or death. The multi-page form collects extensive information about the employer, employee, nature of the accident or disease, and treatment. It requires details about dates, locations, injuries sustained, tasks performed, medical practitioners involved, and earnings. The employer or authorized person must sign to declare the accuracy of the provided particulars. The final section is for official use by NSITF staff to acknowledge receiving and checking the completed form.

Uploaded by

Monday
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Topics covered

  • Workplace Hazards,
  • Risk Management,
  • Injury Types,
  • Employer Responsibilities,
  • Accident Notification,
  • Documentation Requirements,
  • Accident Details,
  • Employee Compensation,
  • Claim Verification,
  • Accident Investigation
862 views3 pages

NSITF Accident Notification Form

This document contains a notification form from the Nigeria Social Insurance Trust Fund (NSITF) regarding an accident, occupational disease, or death. The multi-page form collects extensive information about the employer, employee, nature of the accident or disease, and treatment. It requires details about dates, locations, injuries sustained, tasks performed, medical practitioners involved, and earnings. The employer or authorized person must sign to declare the accuracy of the provided particulars. The final section is for official use by NSITF staff to acknowledge receiving and checking the completed form.

Uploaded by

Monday
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Topics covered

  • Workplace Hazards,
  • Risk Management,
  • Injury Types,
  • Employer Responsibilities,
  • Accident Notification,
  • Documentation Requirements,
  • Accident Details,
  • Employee Compensation,
  • Claim Verification,
  • Accident Investigation

ECS.

CCF01
FEDERAL REPUBLIC OF NIGERIA
NIGERIA SOCIAL INSURANCE TRUST FUND (NSITF)
(Employees’ Compensation Act, 2010)
[Section 5(1) – (3) of the Act]

Notification of Accident/Occupational Disease/Death


Case ID

Instructions: Complete the Form in Triplicate. Use block letters or mark ‘x’ as appropriate. All fields are mandatory.
Indicate as appropriate: Accident: Occupational Disease: Death:
1.0 Employer:

Name

Registration Number
2.0 Employee (Certified copy of Identity documents to be attached):
Surname

First name

Middle name

2.1 Staff ID Number


Staff ID No.

N K
2.2 Earnings of employee at the time of accident
(Attach copy of pay slip as at time of accident)
3.0 Accident:
3.01 Date of accident dd/mm/yyyy

3.02 Time of accident (24 hour; hh: mm)

3.03 Town where accident occurred

3.04 Local Govt. Area

3.05 State

3.06 Date Employee reported accident


dd/mm/yyyy

3.07 Time reported (24 hour; hh: mm)

3.08 What task was the employee performing at the time of accident? __________________________________
-----------------------------------------------------------------------------------------------------------------------------------------------
3.09 Was the accident in the course of his/her work? Yes No

Tel: +234-9-2911810; +234-9-2911811; email: claims@[Link]; website: [Link] Page 1 of 3


3.10 State the nature of injury sustained (see options attached) _______________________________________
_______________________________________________________________________________________________
3.11 Was first aid given in this case? Yes No
3.12 Medical practitioner who treated the employee:
Surname
First name
Practice No

3.13 Number of days per month worked by Employee:


3.14 Date on which employee ceased work due to injury/occupational disease:
(dd/mm/yyyy):

3.15 Date on which the employee resumed work: (dd/mm/yyyy):

(If the Employee will be off duty for an extended period, an interim Medical Report must be submitted regularly)

3.16 Did the Employee die in the accident? Yes No


3.17 If yes, name his registered dependant(s) with you:
Surname
*(Attach list if more than one
First name registered dependants)
Middle name

4.0 Occupational Disease

4.01 Nature of Work:___________________________________________________________________________

4.02 Nature of Disease:_________________________________________________________________________

4.03 Date the disease diagnosed (dd/mm/yyyy):

4.04 Suspected cause of disease:__________________________________________________________________


(State the agent(s) present in the work place and with which he/she had contact that caused the disease; see list
of approved diseases and their responsible agent(s) as contained in the first schedule of the ECA for guidance)
4.05 For how long was he exposed ? Year(s): Month(s): Day(s):

4.06 Date Employee reported the disease (dd/mm/yyyy):

4.07 Did the Employee die as a result of the Occupational Disease? Yes No

4.08 If yes, name his registered dependant(s) with you: (Attach list if more than one dependent)
Surname
First name
Middle name

4.09 Period in your employment (years………………………… /months……………..)


4.10 Please, mention the name(s) and address(es) of former employers, if the employee did not contract the disease
in your employment:_______________________________________________________________________

Tel: +23492911810; +23492911811; email: claims@[Link]; website: [Link] Page 2 of 3


ECS.CCF01
FEDERAL REPUBLIC OF NIGERIA
NIGERIA SOCIAL INSURANCE TRUST FUND (NSITF)
(Employees’ Compensation Act, 2010)
[Section 5(1) – (3) of the Act]

Notification of Accident/Occupational Disease/Death


Case ID

DECLARATION BY EMPLOYER OR AUTHORIZED PERSON


I hereby declare that the particulars, shown above are to the best of my knowledge true and accurate.
Signed on this …………… day of ……………………. 20……..

_______________________ ___________________________ ________________


Name of Authorized Person Signature& Stamp Date
FOR OFFICIAL USE ONLY
Received and checked by: ________________________ ________________ ________________
Name Staff No Sign and Date

Tel: +234-9-2911810; +234-9-2911811; email: claims@[Link]; website: [Link] Page 3 of 3

Common questions

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The NSITF form ensures workplace accidents are verified and accurately recorded by requiring mandatory fields to be filled, such as the date, time, location, and nature of the accident. The form also includes a section for the employer's declaration, verifying the truthfulness of the information and ensuring steps for formal verification, such as signatures and official stamp, are taken .

Providing inaccurate information in the NSITF compensation claim form can lead to false claims or rejection of legitimate claims, legal consequences for fraud, and delay in compensation. It may also hinder effective injury management and resource allocation, impacting both the employee's recovery and the employer's liabilities .

Documenting the employee’s earnings at the time of an accident is essential as it serves as a basis for calculating compensation. Accurate income details ensure the worker receives fair compensation reflecting their usual earnings, thereby facilitating financial stability during recovery and affirming the principles of justice within the compensation process .

According to NSITF guidelines, if a worker requires an extended period off due to a workplace injury, an interim medical report must be submitted regularly. This report provides updates on the employee’s health status and projected return, ensuring that the compensation and reintegration process remains aligned with the employee’s recovery trajectory .

The NSITF form under the Employees' Compensation Act, 2010 serves to formally notify the relevant authorities of an accident, occupational disease, or death that occurs in the workplace. This notification is a mandatory requirement for employers to report such incidents, ensuring they are recorded and managed in compliance with the Act .

Notifications of occupational diseases under the Employees’ Compensation Act, 2010 are documented using specific fields in the NSITF form. Employers must complete details regarding the nature of the work, the nature of the disease, the suspected cause of the disease, including the workplace agent responsible, and the duration of exposure. This structured documentation helps establish the link between occupational conditions and the disease .

The 'tentative date of resume work' is significant in NSITF's documentation as it helps in understanding the severity and impact of the injury on the employee's ability to work. It aids in planning the potential continuity of business operations and in calculating compensation accurately for the period the employee is unable to work. This ensures fair and efficient management of resources related to workplace injuries .

Employers must declare the accuracy of the information submitted in the NSITF forms by signing a declaration. This statement affirms that the particulars provided are, to their best knowledge, true and accurate. An authorized person signs and stamps the declaration, attesting to the form's authenticity and compliance with legal requirements .

If an employee dies due to an occupational disease, the employer must document the incident in the NSITF form by stating whether the employee died and listing any registered dependents. The form requires detailed information about the deceased's period of employment and potential contact with disease-causing agents. This formal reporting ensures dependents may be duly considered for compensation .

The NSITF form facilitates communication between the employer and NSITF regarding compensation claims by standardizing the information that needs to be reported and providing contact details for further queries. It includes fields for comprehensive accident or disease details and a declaration section to ensure accuracy, serving as the primary document for initiating the compensation process .

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