WORKMEN’S COMPENSATION ACCIDENT REPORT FORMThis Form, together with the Wages Statement overleaf, must be completed and returned to the Company immediately.

Employer’s Name & Address

2. (a) Date, time & place of accident :

(b) When was the accident �rst reported to you and by whome?

(c) Names of witnesses

3. (a) Name of injured person

Usual Occupation Age Years (b)

Address (c)

Where is the injured person at present? Married or Single?(d)

Does he/she reside with you? (e)

Relationship to employer (if any) (f )

When did he/she enter your service? (g)

Is the injured person in your regular employment?

(h)

Was he in your direct employ, or in that of a subcontractor? If the latter, state the name & address of the sub-contractor.

(i)

State precisely what he was doing, and how the accident occured (if the accident was due to any defect in machinery, sca�olding, or other equipment, state nature thereof ).

(a)

Was he performing a duty for which he was employed?

(b)

Was he disobeying any rule or order?(c)

Who was in charge?(d)

Was accident due to another person’s negligence? If so, give particulars.

(e)

Nature and extent of injury. If to arm or hand, state whether left or right.

5.

Did he stop work immediately?6.

If not, when did he stop? (date & time)(b)

If taken to a hospital, state which and whether in-patient or out-patient

(c)

Is he disabled now? If not, when did he resume work?(d)

Probable further duration of disablement(e)

(a)

Is there any other information regarding the accident or the injured person with which the Company should be aquainted?

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Yes No

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Have you any other insurance or indemnity covering accidents to your employees?

State whether there are any other earnings or prerequisites such as board and/or lodging, rent, allowances in kind, etc

If so, give (a) Full Description :

(b) Estimated value thereof per annum :

Date : Total Earnings

Average per week

FOR OFFICE USE ONLY

Employer’s Signature

Statement of the injured person’s earnings from me/us during the twelve months preceeding the accident, or during the period pf his employment, if shorter. If he has been absent from work for any part of the period please enter “nil” in the wages column and state the reason.

8. (a)

If so, please give particulars(b) :

Yes No

WEEK ENDEDMONTH

Carried Forward Carried Forward Total

CASHWAGESDAY

WEEK ENDEDMONTH

Bt. fwd. Bt. fwd.

CASHWAGESDAY

WEEK ENDEDMONTH

CASHWAGESDAY

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