FORM 25

Prescribed under Rule 121(3)

REPORT OF ACCIDENT OR DANGEROUS OCCURRENCE RESULTING IN DEATH OR BODILY INJURY

E.S.I.C. Employer’s Code number :	E.S.I.C. Insurance

Number of the injured person :

1.	Name of occupier ( or factory)/employer	:

2. Address of works / premises where the 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.	Name and address of the injured person	:

6.	(a) Sex	:
(b) Age (at the last birthday)	:
(c) Occupation of the injured person	:

7.	Local E.S.I.C. Office to which the injured person is attached	:

8.	Date, shift and hour of accident or dangerous occurrence	:

9.	(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	:

10. (a) Cause or nature of accident or dangerous occurrence	:
(b) If caused by machinery : -

(i) Give the name of machine and the part causing the accident or dangerous occurrence	:

(ii) state whether it was moved by mechanical power at the time of accident or dangerous occurrence	:

(c) State exactly what the injured person was doing at the time of accident or dangerous occurrence	:

(d) In your opinion, was the injured person at the time of accident or dangerous occurrence : -

(i) acting in contravention of 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?:

(e) In case reply to (d) (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	:

11. In case the accident or dangerous occurrence took place while

travelling in the employer’s transport, state whether -

(a) the injured person was travelling as a passenger to or from his place of works :

(b) the injured person was travelling with the express or implied permission of his employer	:

(c) 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	:

(d) the vehicle is being/not being operated in the ordinary course of public transport service	:

12. In case the accident or dangerous occurrence took place while meeting emergency, state :-

(a) its nature ; and	:

(b) whether the injured person at the time of accident or dangerous occurrence was employed for the occurrence was trade or business in or about the premises at which the accident or dangerous occurrence took place :

13. Describe briefly how the accident or dangerous occurrence took place	:

14. Names and addresses of witnesses
(1)	:
(2)	:

15. (a) Nature and extent of injury(e.g. fatal, loss of finger, fracture of leg, scald, scratch followed by sepsis, etc.)	:

(b) Location of injury (e.g. right leg, left hand, left eye, etc.)	:

16. (a) If the accident or dangerous occurrence was not fatal, state whether the injured person was disabled for more than 48 hours	:

(b) date and hour of return of work	:

17. (a) Physician, dispensary or hospital from whom or which the injured person received or is receiving treatment	:
(b) Name of dispensary/panel doctor elected by the injured person	:

18. (a) Has the injured person died ?	:
(b) 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 of manager/employer :

Name, designation and address of manager/employer	:

Date of dispatch of report	:

(This space is to be completed by the Inspector of Factories)

District ………………………….. Date of receipt	:

Number of the accident or dangerous occurrence: Causation	:

Other particulars (e.g. fatal, leg injury, arm injury, etc.) :

Date of investigation :

Result of investigation :