The Code on Social Security (Arunachal Pradesh) Rules, 2021
Form XXVII
Official text
Open in the official PDF (p. 61)
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[See Rule 68]
STATEMENT/ REPORT OF FATAL ACCIDENTS
To,
Competent Authority,
...............................
Sir,
1. I have the honor to submit the following statement of an accident which occurred on (date),
at (here enter details of premises) and which resulted in the death of the
employee/employees of whom particulars are given in the statement annexed.
2. The circumstances relating to the death of the employee/employees were as under: -
(a) Time of accident.
(b) Place where the accident occurred.
(c) Manner in which deceased was/were employed at the time.
(d) Cause of the accident.
(e) Any other relevant particulars.
3. I am responsible for payment of compensation.
4. Details of employee:
(a) Name of the employee …………….
(b) Age of the employee ………………..
(c) Wages of the employee ………………
5. The establishment is not responsible for payment of compensation due to reasons
mentioned below......................................................................................
(Signature and designation
of person making the statement)