The Code on Social Security (Lakshadweep) Rules, 2025
Form XVII
Official text
Open in the official PDF (p. 50)
Tables and forms lose their layout when extracted; the PDF is the authoritative version.
[See rule 28]
Statement of Fatal Accidents
Sir,
1. I have the honour 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. Brief History of Accident
c. Place where the accident occurred.
d. Manner in which deceased was/were employed at the time.
e. Cause of the accident.
f. Accident reported at the local police station (Copy of FIR if any)(Y/N)
g. Any Other Relevant Information
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)
Name:
Mobile:
Address: