Form VI

(See Rule-8)

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 establishment/

(Registration number of 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) Sex :

(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 him 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 him; or

(ii) acting in contravention 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. :

11. 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

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 :

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 his 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 hour of return of 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: