Form 09

(See Rule-14 & 15)

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 :

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 theaccident 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: