The Uttar Pradesh Code on Social Security Rules, 2026
Form XX
Official text
Open in the official PDF (p. 156)
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{ See Rule 63}
Notice book of the accidents
Name of the Establishment……………….………
Nature of Business ……………………….………
Date of opening………………………………..…
Registration no (if any)-………………………..…
Name of the employer/occupier…………………..
To be filled up by or in behalf of employee
1. Date and time of accident: ………………………….
2. Date and time of notice: …………………………….
3. Name of person injured: ……………………………
4. Address: ………………………………………………
5. Cause of injury: ………………………………………
Signature /Thumb-impression
of the person giving information
To be filled up by employer or his agent
Date of short detail of name of the injured rate of of Place of Nature of Names of eye-
Accident accident person wages accident injuries witnesses
1 2 3 4 5 6 7
Amount of
whether wheather wheather whether accident Amount of
Compensation Date of payment
accident accident result accident result result in compensation
deposited to or deposit of
r de es au thlt in i dn
i
st ao bta lel
ment
i dn
i
sp aa br lt ei mal
ent
t de im sap bo lera mry
en t
p oa
r
i hd
i
sto employee
ac uo tm hp oe rit te yn t compensation
8 9 10 11 12 13 14
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