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  NOTICE OF INJURY FORM  
     
 

Particulars of Accident to be furnished by the employer
Answering these questions does not imply that the Employer admits liability or that the Workman will make a claim.

1.
  THE EMPLOYER    
  Name * Full Name is required.  
  Address * A address is required.  
  Email * A value is required.Invalid format.  
  Period  
  Phone No  
  Date of payment of last premium  
  Policy No  
  Trade or Business  
  No. of Employees  
  Have you any power-driven machinery  
         

2 THE INJURED PERSON
 
a) Name
b) Age
c) Address (Residential)
d) Married or Single
e) Normal occupation
f) On what date was the injured person first engaged by you?
g) Has the injured person been previously involved in any accident? If so please give details
h) Is he/she in your direct employ? If not, give name and address of contractor
   
3. THE ACCIDENT
 
a) Where did the accident occur?
Date
Time
Place
b) Name the hospital/clinic taken to
4.
(a) State fully the work upon which he/she was engaged at the time of the accident
(b) Specify if the accident happened within or outside your premises
(c) State below in the section marked 'EARNINGS' the earnings during the past 12 months  
5.
(a) How did the accident occur?
(b) State the nature of the injury?
6.
(a) Date the injured person ceased work on account of the injury?
7.
(a) When and to whom did he/she first report the accident?
8.
State fully the nature of the injuries. If accident happened in connection with any machinery, give name of machine and state part causing accident
9.
State names of any witnesses
 
10.
Was he/she under the influence of drugs or drinks or was he/she guilty of any mis-conduct or breach of orders or rules? If so please explain fully
 
11.
Was the accident due to anyone's negligence? If so, give particulars
12.
Is he/she able to perform any part of his/her duties?
13.
What is the probable period of disablement, in your opinion?
  I/We certify that the above wages statement overleaf are true to the best of our/my knowledge and belief

Date :    Designation:
  WAGES STATEMENT
  CASH WAGES, and (if supplied by the Employer), the value of FOOD FUEL, and QUARTERS and other prerequisites.
Complete on monthly or weekly basis, ignoring whichever of the first two columns is not applicable
If paid monthly
MONTH ENDING		 If paid weekly
WEEKLY ENDING		 CASH WAGES
(use upper box if monthly)		 Values of Food, Fuel and Quarters,
and other prerequisites		 Date of any absence from work
And reasons for absence.
1. 1.
2. 3.
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3. 5.
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4. 7.
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5. 9.
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6. 11
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7. 13
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8. 15
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10. 19
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11. 21
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12. 23
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Totals on monthly basis        
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THE OBJECT OF THIS FORM IS TO ASCERTAIN THE EXACT AVERAGE EARNINGS OF THE INJURED PERSON. IT SHOULD BE CAREFULLY COMPLETED GIVING THE FIGURES REQUIRED FOR THE TWELVE MONTHS PRIOR TO THE ACCIDENT OR FOR SUCH SHORTER PERIODS AS HE/SHE MAY HAVE BEEN IN YOUR SERVICE
Please note that details of all items to be insured and their respective sums should be sent by fax or mail to our Corporate Office for further processing.
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