Department of Labour and Employment FORM - 17 (Prescribed under rule 106) Notice of Accidents 1. Name of occupier or employer: E.S.I. Employer's Code No.: 2. Address of works / premises where accident took place 3. Nature of Industry E.S.I. Insurance No.: 4. Branch or department and exact place where the - accident took place 5. Name and address of the injured person - 6. (a) Sex - (b) Age (last birthday) - (c) Occupation of the injured person - 7. Local E.S.I. Office to which the injured person is attached 8. Date and hour of accident 9. (a) hour at which the injured person started work on the day of accident (b) Whether wages in full or part are payable to him for the day of the accident 10. Cause or nature of accident 11. Cause of accident 12. Cause of accident (a) If caused by machinery (i) Give name of machine and the part causing the accident (ii) State whether it was moved by mechanical power at the time (b) State exactly what the injured person was doing at that time (c) In your opinion, was the injured person at the time of accident (i) Acting in contravention of provisions of any law applicable to his employer, 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 employer's trade or business 13. In case the accident happened while traveling in the employer's transport, state whether (i) The injured person was traveling as a passenger to or from his place of work (ii) The injured person was traveling 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 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 14. In case the accident happened while meeting emergency, state (i) Its nature (ii) Whether the injured person at the time of accident was employed for the purpose of his employer's trade or business in or about the premises at which the accident took place 15. Describe briefly how the accident occurred 16. Name and address of witness: 1. 2. 17. (a) Nature and extent of injury (i.e. fatal loss of finger, fracture of leg, scalp or scratch and followed by sepsis) (b) Location of injury (right leg, left hand or left eye, etc.) 18. (a) If the accident is not fatal , state whether the injured person was disabled for more than 48 hours (b) Date and hour of return to work 19. (a) Physician, dispensary or hospital from whom or in which the injured person received or is receiving treatment (b) Name of dispensary / panel of doctor elected by the injured person 20. (i) has the injured person died? (ii) If so, date of death - I certify that to the best of my knowledge and belief the above particulars are correct in every respect. Signature : Name and designation of the Occupier or Manager/Employer : Employer's address and code No. : (This space is to be completed by the Inspector of Factories) District : Date of receipt : Accident No : Causation : Other particulars (e.g. fatal, leg injury, arm injury etc.) Date of investigation: Result of investigation:
