Form VI

{See rule 10(1)}

NOTICE OF ACCIDENT OR DANGEROUS OCCURRENCE

E.S.I.C. Employer’s Code number:

E.S.I.C.Insurance Number of the injured persons:

1. Name of employer:

2. Address of works/premises where the accident

or dangerous Occurrence took place:

3. Nature of industry and LIN/Registration no of the establishment:

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. FIR Dated…………....Number… ................................... Police Station

8. Local E.S.I.C.Office to which the injured person is attached:

9. Date,shift and hour of accident or dangerous occurrence:

10. (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 him for the

day of the accident or dangerous occurrence:

11. (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

him;or

ii. Acting incontravention of any orders given by or on

behalf of his employer; or

iii. Acting without instructions from his

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:

12. In case the accident or dangerous occurrence took place while

travelling in the employer ‘s transport, state whether -

(a) the injured person was travelling as a passenger to or

from his place of works;

(b) the injured person was travelling with the express or

implied permission of his 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:

13. 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 his

employer‘s trade or business in or about the premises at

which the accident or dangerous occurrence took place:

14. Describe briefly how the accident or dangerous occurrence took

place:

15. Names and addresses of witnesses :(1)

(2)

16. (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.)

17. In case of fatal accident-

(a) Name of the Hospital where worker was declared dead

(b) Date of Death Certificate and Death Certificate Number.

(c) Date of intimation to concern ESIC Authority

(d) Date of intimation to concern Commissioner for

Employees Compensation:

18. (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 hour of return of work :

(c) Date of intimation to concern ESIC Authority

(d) Date of intimation to concern Commissioner for

Employees Compensation:

19. (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:

20. (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.

Date of dispatch of report

Signature and Name and Designation of

owner/employer/manager/agent