deZpkjh jkT; chek fuxe E.S.I. CORPORA TION nq?kZVuk fjiksVZ ACCIDENT REPORT izi=k 12 ¼fofu;e 68½ FORM 12 (REGULATION 68) f u ; k st d d k u k e @ Name of Employer d wV l a[ ; k @ Code No. ' k k [ k k d k ; k Zy ; @ Branch Office dk;Z ;k O;olk; dk Lo:i chekÑr O;fDr dk uke o irk Nature of Industry/ business Name & Address of insured person chekad Insurance No. ifjlj dk irk tgka nq?kZVuk gqbZA Address of premises where accident happened foHkkx Deparment ikjh le;Shift Hour nq?kZVuk dgk¡ gqbZExact place of accident fyax Sex vk;q ¼fiNyk tUe fnu½Age (Last birthday) O;olk; Occupation nq?kZVuk dh rkjh[k o le;Date and hour of Accident fdl le; dk;Z 'kq# fd;k x;kHour at which work was sarted fdl izdkj dh vkSj fdruh pksV yxh gS ¼mnkgj.kkFkZ vxqyh dh ?kkrd gkfu] Vkax dk VwVuk] tyuk vkfn½Nature and extent of injury (e.g total loss of finger, fracture ofleg. scald etc. pksV dgka yxh gS ¼nk;ka½ @ ck;ka gkFk] iSj ;k vk¡[k vkfn½Location of injury (right/left hand, leg or eye etc. ;fn nq?kZVuk xHkhj ugha gS rks crkb,] fd D;k {kfrxzLrO;fDr dke ij okil vk x;k gS\ ;fn gk¡] rks dke ij okil vkus dk le; o rkjh[k crkb,Aif the accident is not fatal state whether the injured person has returned to work?If so, give date & hour of return to work x`r chekÑr O;fDr ds ekeys esa e`R;q dh rkjh[kDate of Death in case the insured person died D;k nq?kZVuk ds fnu ds fy, mldh iwjh etnwjh ns; gS ;k mldk Hkkx Whether wages in full or part are payable to him for the day of accident gka Yes ugha No D;k chekafdr O;fDr nq?kZVuk ds fnu vf/kfu;e dh /kkjk 2 ¼9½ ds v/khu deZpkjh Fkk vkSj D;k ml fnu ds fy, va'knku ns; Fkk ftl fnu nq?kZVuk gqbZ FkhA Whether the injured person was on the dayaccident an employee as defined in Sec 2 (9) of the Act and whether contribution was payableby him/her for the day on which the accidentoccured. lkf{k;ks ds uke vkSj iÙksName and address of witnesses 12chekaÑr O;fDr dk vkS"k/kky;@chek fpfdRlk O;olk;h Dispensary/IMP of injured person MkDVj ;k vkS"k/kky; ftlus {kfrxzLr O;fDr dk mipkj fd;k gS ;k fd;k tk jgk gSA Dr. or dispensary from where injured person received or receiving treatement. nq?kZVuk dk laf{kIr C;kSjkBrief description of the accident fVIi.kh%& ;fn nq?kZVuk vkikr ds le; dke djrs le; gqbZ gS rks mi;qZDr fooj.k esa ;g crk, fd og fdl izdkj dh Fkh vkSj ;g Hkh crk, fd D;k nq?kZVuk ds le; {kfrxzLr O;fDr ,sls ifjlj esa tgka nq?kZVuk gqbZ gS] vius fu;kstd ds O;kikj ;k djksckj ds iz;kstu ds fy, fu;ksftr fd;k x;k FkkA Note:-In case the accident happened while meeting emergency. indicate in the description above its natue and also whether the injured person at time of accident was employed for the purpose of his employer's trade or business in or about the premises which the accident took place. ¼d½ nq?kZVuk dk dkj.k ;fn mlds }kjk (a) CAUSE OF ACCIDENT if caused by e'khujh ¼1½ e'khu vkSj mlds Hkkx dk uke nhft, ftlls nq?kZVuk gqbZ gks vkSj%& gkaugha Machinery (1) Give name of machine and part causing the accident, and: Yes No ¼d½ ;g crkb;s dh D;k og ml l; ;kaf=kd 'kfDr ls pykbZ tk jgh Fkh\ (a) State whether it was moved by mechanical power at that time.? ¼[k½ ;g Bhd&Bhd crkb;s fd {kfrxzLr O;fDr ml le; D;k dj jgk Fkk (b) State exactly what the injured person was doing at that time? ¼x½ D;k {kfrxzLr O;fDr nq?kZVuk ds le; fuEufyf[kr ds mYya?ku esa dk;Z dj jgk Fkk\ gka Yes ugha No (c) Was the injured person at that time of accident acting in contravention of? ¼1½ mldks ykxw fdlh fof/k ds miyC/k ;k the provisions of any law applicable to him or ................................................................ ¼2½ vius fu;kstd }kjk ;k mldh vksj ls fn;k x;k dksbZ vkns'k any orders given by or on behalf of his employer............................................................ ¼3½ fu;kstd ds vuqns'kksa ds fcuk dk;Z djuk acting without instruction from his employer.................................................................. ¼?k½ ;fn ¼x½ ¼1½ ¼2½ ;k ¼3½ dk mÙkj gka esa gS rks ;g dFku dhft, fd D;k dk;Z fu;kstd ds O;kikj ;k dkjksckj ds iz;kstukFkZ vkSj mlds laca/k esa fd;k x;k FkkA (d) In case reply to C (1), (2) or (3) is YES, state whether the act was done for the purpose of and in connection with the employer's trade or business. ;fn nq?kZVuk fu;kstd ds okgu esa ;k=kk djrs le; gqbZ gks] rks ;g crkb, fd O;fDr fdl :i esa ;k=kk dj jgk FkkA In case the accident happened while TRAVELLING in the employer's transport, state whether the injured person was travelling. gka Yes ugha No 1- vius dke ds LFkku dks ;k ls ;k=kh ds :i esa as a passenger to or from his place of work 2- vius fu;kstd dh vfHkO;Dr ;k foof{kr vkKk ls With the express or implied permission of his employer 3-D;k okgu fu;kstd ;k mldh vksj ls ;k fdlh vU; O;fDr }kjk pyk;k tk jgk Fkk ftllsmldk miyC/k fu;kstd ds lkFk fdlh Bgjko ds vuqlkj fd;k gSA the transport was being operated by or on behalf of the employer or some other person by whom it is provided in pursuance of arrangements made with the employer. D;k okgu yksd ifjogu lsok ds ekewyh vuqØe esa pyk;k tk jgk Fkk@ugha pyk;k tk jgk Fkk The vehicle was being/not being operated in the ordinary course of public transport service. eSa izekf.kr djrk@djrh gwa fd mDr fof'kf"V;ka esjh loksZÙke tkudkjh vkSj fo'okl ds vuqlkj gj izdkj ls lgh gSaA I certify that to the best of my knowledge and belief the above particulars are corect in every respect. fjiksVZ Hkstus dh rkjh[k gLrk{kj Date of despatch of report Signature lsok esa TO ______________________________ inuke ¼eksgj lfgr½ ______________________________ Designation (With stamp) Mk;jh la[;k vkSj rkjh[k 'kk[kk dk;kZy; izcU/kd Diary No. & Date Branch Office Manager
