The Code on Social Security (Mizoram) Rules, 2026
Form XVII
Official text
Open in the official PDF (p. 50)
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(SEE RULE 16)
STATEMENT OF FATAL ACCIDENTS
To,
Competent Authority,
...............................
Sir,
1. I have the honour to submit the following statement of an accident which occurred in (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 the 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 the payment of compensation.
4. Details of employee ………………………….
a. Name of the employee …………….
b. Age of the employee ……………….
c. Wages of the employee ………………
d.
5. The establishment is not responsible for payment of compensation due to reasons mentioned
below.............................................................................
(Signature and designation
of person making the statement)