Form 13

(see rule 30(1), (2) & (3))

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 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 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

‍627

Date of dispatch of report :

Place: