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
5. Employees State Insurance number (if covered)
6. Name and address of the injured person.
7. (a) Sex
(c) Occupation of the injured person
(d) Monthly wages of the person injured.
8. Local Employees State Insurance Office to which
9. Date, shift and hour of accident or dangerous
10. (a) Hour at which the injured person started
(b) Whether wages in full or part are payable
11. Cause or nature of accident or dangerous occurrence.
(b) state exactly what the injured person was doing at that time.
(c) in your opinion, was the injured person at the
(d) in case reply to (c), (i), (ii), or (iii) is
12.in case the accident or dangerous occurrence
13. In case the accident or dangerous occurrence happened while meeting an emergency, state-
14. Describe briefly how the accident or dangerous
15. Names and addresses of witness (1)
16. (a) Nature and extent of injury (e.g. fatal, loss
(b) Location of injury (right leg, left hand
17. (a) If the accident is dangerous occurrence and
(b) Date and hour of return to work.
18. (a) Physician, dispensary or hospital from whom
(b) Name of dispensary / panel doctor elected by
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.
|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)
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 ;
Sev (W.M.B. or G.):