Employees' State Insurance (General) Regulations, 1950
FORM 16 : Accident Report from Employer
1. Name of employer _____________
2. Employer's Code No ______________
3. Address of premises where accident happened ____________
4. Nature of industry or business ________________________
5. Department, shift, hours, (if any), and exact place where the accident happened. ___________________________________________________________________
6. Name of the injured person ____________________
7. Insurance no _______________________________
8. Address of the injured person ____________________
9. (a) Sex ___________________
(b) Age (last birthday)______________
(c) Occupation of injured person ____________
(d) Local office to which attached ____________
10. Date and hour of accident ____________
11. (a) Hour at which he started work on day of accident.
(b) Whether wages in full or part are payable to him for the day of his accident.
3[(c) Whether the injured person was on the day of accident an employee as defined in section 2(9) of the Act and whether contribution was payable by him for the day on which the accident occurred.]
12. Cause of accident:
(a) If caused by machinery,-
(i) give name of the machine and part causing the accident, and
(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 injured person at the time of accident,-
(i) acting in contravention of the provisions of any law applicable to him;
(ii) acting in contravention of any orders given by or on be half of his employer;
(iii) acting without instructions from his employer.
(d) In case reply to (c) (i), (ii) or (iii) is in 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 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; and
(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 was 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 witnesses:
17. (a) Nature and extent of injury (e .g., fatal, loss of finger, fracture of leg, scald, etc.).
(b) Location of injury (right leg, left hand or left eye, etc.).
(c)(i) If the accident is not fatal state whether the injured person has returned to work.
(ii) If so, date and hour of return to work.
18. (a) Physician, dispensary or hospital from whom or where the injured person received or is receiving treatment.
(b) Name of dispensary/panel doctor, elected by the injured person
19. (i) Has injured person died (i)
(ii) If so, date of death (ii)
I certify that to the best of my knowledge and belief the above particulars are correct in every respect.
Date of dispatch of report _______________
Employer's name ____________
Code No ____________