FORM NO. 18
[prescribed under Rule 96 and under Regulation 68 of Employees State insurance Act, 1948]

Notice of accident or dangerous occurrence resulting in death or bodily injury

1. Name of occupier (Factory/Employer)

    Employees State Insurance Employee Code No.

2. Address of works/premises where accident or dangerous occurrence took place.

3. Nature of Industry.

4. Branch or Department and exact place where the
accident or dangerous occurrence took place 

5. Employees State Insurance number (if covered)

6. Name and address of the injured person.

7. (a) Sex
    (b) Age (last birthday)

    (c) Occupation of the injured person

    (d) Monthly wages of the person injured.

8. Local Employees State Insurance Office to which
the injured person is attached.

9. Date, shift and hour of accident or dangerous
occurrence.

10. (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.

11. Cause or nature of accident or dangerous occurrence.
      (a) if causes is by machinery

(i) give name of the machine and the part
which involved the accident or dangerous occurrence.

(ii) state whether it was moved by mechanical
power at that time.

     (b) state exactly what the injured person was doing at  that       time.

     (c) 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.

      (d) in case reply to (c), (i), (ii), or (iii) is in the
        affirmative, state whether the act was done for the purpose of  and in connection with the employers trade or business.

12.in case the accident or dangerous occurrence
happened while travelling in the employer's transport, state whether -

(i) the injured person was travelling as a passenger to or from his place of work.

(ii) the injured person was travelling with the express or implied permission of his employer.

(iii) 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

(iv) the vehicle being/not being operated in
the ordinary course of public transport
service.

13. In case the accident or dangerous occurrence happened while meeting an emergency, state-

(i) its nature.

(ii) 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.

14. Describe briefly how the accident or dangerous
occurrence occurred.

15. Names and addresses of witness                   (1)

                                                                          (2)

16. (a) Nature and extent of injury (e.g. fatal, loss
of fingers, fracture of leg, scaled or scratch
and followed by sepsis).

(b) Location of injury (right leg, left hand
or left eye, etc.)

17. (a) If the accident is dangerous occurrence and
is not fatal, state whether the injured person
was disabled for more than 48 hours.

(b) Date and hour of return to work.

18. (a) Physician, dispensary or hospital from whom
or in which, the injured person received or
is receiving treatment.

(b) Name of dispensary / panel doctor elected by
the injured person.

19. (i) Has the injured person died.

      (ii) If so, date of death.

 


Note:- (1) To be completed in legible handwriting or Type writing.

           (2) For purposes of item 7-(d) in this Form the definition of wages in Section 2 (m) of the Workmen's                 Compensation Act, 1923 (Central Act VIII of 1923) and the method laid down in Section 5 of  the said Act, regarding calculation of monthly wages shall be adopted.

I certify that to the best of my knowledge and belief the above particulars
are correct in every respect.

 

Signature

Date of dispatch of report  Name and Designation of Occupiere or manager/Employer

 

 

   Employer's address and E.S.I. Code No ..............

 

                                                      

(This space is to be completed by the Inspector of Factories)

District
Number of the accident or dangerous occurrence ;
Industry No. ;
Other particulars (e.g. fatal, leg injury, arm injury etc.) ;
Date of investigation ;
Result of investigation ;

Date of receipt ;
Causation No.:
Sev (W.M.B. or G.):