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 time of accident or dangerous occurrence. (iii) 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 (i) acting in contravention of provisions of any 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 employers 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 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 of 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 competed 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 month 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 despatch of report Name and Designation of Occupiere of 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.):
