NOTICE OF ACCIDENT
1. Name of Occupier (Or Factory) :
Employer
2. Address of Factory / premises where accident took :
place.
3. Nature of industry :
4. Branch or department and exact place where the :
accident took place
5. Name and address of the injured :
6. a) Sex :
b) Age (Last birth day) :
c) Occupation of the injured person :
7. Local E.S.I. Office to which the injured person is :
attached
8. Date, shift and hour of accident :
9. a) Hour at which the injured person :
started work on the day of accident
b) Whether wages in full or part are payable to him :
for the day of the accident
10. Cause of accident :
a) If caused by machinery :
i) Give name of the machine and :
the part causing the accident
ii) State whether it was moved by :
Mechanical power at that time.
b) State exactly what the injured person was doing at :
that time.
c) In your opinion, was the injured person at the
time of accident
i) acting in contravention of provisions of any :
law applicable to him?
Or
ii) acting in contravention of any :
orders given by or on behalf of
his controlling officer?
Or
d) In case reply to ( c), (i), (ii) or (iii) is :
in the affirmative, state whether the act was done
for the purpose of and in connection with the
employer's trade or business
Contd. to Page-2
Page: 2
11. In case of the accident happened while travelling in the :
employer’s transport, state whether
i)the injured person was travelling as a passenger to or :
from his place of work;
ii) the injured person was travelling with the express or :
implied permission of the employer;
iii) the transport is being operated by or on behalf of the :
employer or some other person by whom it is provided
in pursuance of arrangement made with the employer;
iv) the vehicle was being / not being operated in the :
ordinary course of public transport service;
12. In case the accident happened while meeting emergency, :
state
i) Its nature :
ii) Whether the injured person at the time of accident was :
employed for the purpose of his employer’s trade or
business in or about the premises at which the accident
took place.
13. State how the accident occurred :
14. Names and address of witnesses :
a) ____________________________________________
b) ___________________________________________
a)15. a) Nature and extent of injury (e.g. fatal, loss of finger, :
fract fracture of leg, scale of scratch and followed by
b) Sepsis).
b) Location of injury (right leg, left hand or left eye :
etc.)
16. a) If the accident is not fatal, state whether the injured :
person was disabled for 48 hours or more
b)Date and hour of return to work :
17. a) Physician, dispensary or hospital from whom or in :
which the injured person received or is receiving
treatment
b) Name of dispensary/panel doctor selected by the :
injured person.
18. i) Has the injured person died :
ii) If so, date of death :
I certify that to the best of my knowledge and belief the above particulars are correct in every respect.
Date:
Signature of the Sr. Manager
__________________Department, BTPS.
