Form XI

(See rule 7(1) and rule 7(2))

NOTICE OF ACCIDENT OR DANGEROUS OCCURRENCE

E.S.I.C. Employer’s Code number:

E.S.I.C. Insurance

Number of the injured person :

1. Name of employer :

2. Address of

works / premises

where the accident

or dangerous

Occurrence took place :

3. Nature of

industry and

LIN of the

establishmen

t:

4. Branch or department and

Exact place where the accident

or dangerous occurrence took

place :

5. Name and address of the injured person :

6. (a) Gender :

(b) Age (at the last birthday) :

(c) Occupation of the injured person :

7. Local E.S.I.C. Office to which the

injured person is attached :

8. Date, shift and hour of accident

or dangerous occurrence :

9. (a) Hour at which the

injured person started

work on the day of

accident or dangerous occurrence :

(b) Whether wages in

full or part are payable

to them for the day of

the accident or

dangerous occurrence

:

10. (a) Cause or nature of accident

or dangerous occurrence :

(b) If caused by machinery-

(i) Give the name

of machine

and the part

causing the

accident or

dangerous

occurrence :

(ii) State whether

it was moved

by mechanical

power at the

time of

accident or

dangerous

occurrence :

(c) State exactly what the

injured person was doing at

the time of accident or

dangerous occurrence :

(d) In your opinion,

was the injured person at

the time of accident or

dangerous occurrence -

(i) acting in

contravention of

provisions of any law

applicable to them; or

(ii) acting in

contravention of any

orders given by or on

behalf of their

employer; or

(iii) acting without

instructions from their

employer?

(e) In case reply to (d)

(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. :

11. In case the accident

or dangerous

occurrence took place

while travelling in the

employer’s transport,

state whether-

(a) the

injured

person

was

travellin

g as a

passenge

r to or

from

their

place of

works; :

(b) the injured person

was travelling with

the express or

implied permission

of their employer; :

(c) the transport is being operated

by or on behalf of the

employer or some

other person by whom

it is provided in

pursuance of

arrangements made

with

the employer; and :

(d) the vehicle is

being/not being

operated in the

ordinary course

of public transport service :

12. In case the accident

or dangerous occurrence

took place while

meeting emergency,

state-

(a)its nature; and

(b) whether the injured

person at the time of

accident or dangerous

occurrence was employed

for the purpose of their

employer’s trade or

business in or about the

premises at which the

accident or dangerous

occurrence took place.

:

13. Describe briefly how the accident or

dangerous occurrence took place :

14. Names and addresses of

witnesses : (1)

(2)

15. (a) Nature and

extent of injury(e.g.

fatal, loss of finger,

fracture of leg,

scald, scratch

followed by sepsis, etc.) :

(b) Location of injury

(e.g. right leg, left hand,

left eye, etc.)

16. (a) If the accident or dangerous

occurrence was

not fatal, state

whether the

injured person

was disabled for

more than 48

hours :

(b) date and time when the injured person returned to work: :

17. (a) Physician, dispensary or

hospital from whom or which

the injured person

received or is receiving treatment :

(b) Name of dispensary/panel doctor

elected by the injured person :

18. (a) Has the injured person died ? :

(b) If so, date of death :

I certify that to the best of my knowledge and belief the above particulars are correct in every respect.

Signature and Name and Designation of owner/ employer /manager/agent

Date of

dispatch of

report :

Place: