Form XIX

(See Sub-Rule (2) of Rule 47)

To:

------------------------------------------

Sir,

The report about an accident which occurred on---------------------at------------------

-(here enter details of premises) and which resulted in death/disablement of the

employee is furnished as given below: -

1. (a) Name of the employee---------Sex------------Age---------------

(b) Monthly wages

(c) Name of the employment

(d) Name of the employer

(e) Full postal address of the employee/dependents (local & permanent

both)

(f) Full postal address of the factory/establishment where its registered

office is located.

2. The circumstances leading to death/disablement of the employee: -

(a) Time of the accident

(b) Place where the accident occurred

(c) Manner in which deceased was/were employed at that time

(d) Cause of the accident

3. The amount of money deposited by the employer with the competent

authority under section 81.

4. (a) Details of compensation paid, if any

(b) Particulars of money invested for the benefit of dependents of deceased

employee.

5. Documents forwarded (in original) as under: -

(a) Death certificate

(b) Disablement certificate from the competent medical authority

(c) Receipt for deposit of compensation by the employer

(d) Statement of disbursement

(e) Receipt of compensation from the employee/dependents

(f) Memorandum of Agreement, if any