CHPCHP W1 EMPLOYEES'STATE INSURANCE CORPORATION ===================================== W0 * Form-16 (Regulation-68) * * ACCIDENT REPORT * *************************** -------------------------------------------------------------------------------- Name & Address of the Employer | Local Office: |----------------------------------------- | Code No. : |----------------------------------------- | Insurance # : --------------------------------------|----------------------------------------- Address where the Accident happened | Name of I.P.: | Father/Hus- : | band Name : | Address : --------------------------------------| : Nature of Industry/Business |----------------------------------------- | Dispensary : --------------------------------------|----------------------------------------- Department : | Sex : --------------------------------------|----------------------------------------- Shift Hours: | Age : --------------------------------------|----------------------------------------- Exact place of Accident | Occupation/ : | Designation : --------------------------------------|----------------------------------------- Dt.& Hr.at which : - - | Date & Hour : - - work was started : | of accident : -------------------------------------------------------------------------------- Whether wages/salary in full or part are payable : to the Injured Person for the day of Accident : -------------------------------------------------------------------------------- Whether the Injured Person was an Employee as defined: in Sec. 2(9) of the Act on the day of accident : -------------------------------------------------------------------------------- Whether contribution was payable by him/her : for the day on which Accident occured. : -------------------------------------------------------------------------------- Nature and extent of Injury : -------------------------------------------------------------------------------- Location of Injury : -------------------------------------------------------------------------------- If the accident is not fatal state whether the : Injured person has returned to work. : -------------------------------------------------------------------------------- If so, date & hour of return to work : -------------------------------------------------------------------------------- Brief discription of the Accident : -------------------------------------------------------------------------------- Name & Ins.No. of Witnesses | Doctor/Dispensary/Hosp-: | ital from whom/whereThe: 1. | injured person received: | or receiving treatment : |--------------------------------------------------- 2. | Has the Injured Person : | died : |--------------------------------------------------- | if so, date of Death : - - -------------------------------------------------------------------------------- - 2 - * Form-16 (Regulation-68) * * ACCIDENT REPORT * *************************** CAUSE OF ACCIDENT 1. If caused by Machinery | (a)Name of machine and part causing the Accident | (b)State whether if was moved by Mechanical Power | at that time? | (c)State exactly what the Injured Person was doing | at that time? | (d)Was the Injued person at the time of Accident | acting in contravention of | | (i) The provisons of any law applicable to him | (ii) Any order given by or on behalf of his employer| (iii) Acting without the instruction from his | employer | (iv) In case reply to column(i),(ii) or (iii) is | YES state whether the act was done for | the purpose of and business inconnection | with the employer's trade or | | 2.In case the Accident happended while | travelling in the employer's transport state | whether the Injured prtrson was travelling | (a) As a passenger to or from his place of work | (b) With the express or impiled permission of his | employer | (c) The transport was being operated by or on behalf| of the employer or some other person | by whome it is provided in purseance of | arrangements made with the employer. | (d) The vehicle was being/not being operated in the | ordinary course of Public transport service. | | 3.In case the Accident happended while | meeting emergency. | (a) Its nature | (b) Whether the injured person at the time of | accident was employed for the purpose of him | employer's trade or business in or about the | premises at which the Accident took place. | I certify that to the best of my knowledge and belief the above particulars are correct in all respect. SIGNATURE : Date of dispatch of the Accident Report DESIGNATION : Director/Auth.Sign. --------------------------------------------------------------------------------G FOR OFFICIAL USE H Diary No.& date Manager Local Office