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Employee's compensation computation and statement

Yes / No (1)

Yes / No (2)

Yes / No / Disputed

Commuting / Not commuting

Death / Permanent total disablement / Permanent partial disablement / Temporary disablement

More than three days / Three days or less

Attributable / Not attributable

Listed occupational disease / Accident

Date of birth of the employee

Date of the accident

Date of death

Date of payment or deposit

Date temporary disablement began

Date temporary disablement ended

Monthly wages in Rs

Medical expenses in Rs

Payments already made in Rs

Advance paid to a dependant in Rs

Loss of earning capacity %

Name and registration of the establishment

Name, code and designation of the employee

Date, time and place of the accident and injury

Result of the injury and medical evidence

Date of birth and completed age

Relevant factor applied

Monthly wages, actual and as capped

Loss of earning capacity and source

Compensation computed in Rs

Payments deducted in Rs

Funeral expenses in Rs

Medical expenses reimbursed in Rs

Interest included and period

Total paid or deposited in Rs

Mode and reference of payment or deposit

Insurer, policy and claim reference

Name of the preparer

Designation of the preparer

DD.MM.YYYY (1)

Name of the establishment

Name of the authorised signatory

Designation of the authorised signatory

DD.MM.YYYY (2)

Report of an accident and deposit of compensation with the competent authority

Name of the establishment

Address of the establishment

Reference number

DD.MM.YYYY (1)

Office and address of the competent authority

Death / serious bodily injury

Name of the employee

Designation of the employee

Date of the accident

Date and time of the OSH notice

Name, address and registration of the establishment

Name and designation of the employer

Name, parentage and address of the employee

Date of birth, age, date of joining and code

Designation and work of the employee

Direct employee / Engaged through a contractor

Monthly wages and twelve-month wages

Reason the employee was not insured

Date, time and place of the accident (1)

Work being done and machinery involved

How the accident happened

Nature of the injury

Medical attention given

Date, time and place of death and post-mortem

Category of serious bodily injury and expected absence

Police intimation and reference

Witnesses

Dependants known to the establishment

Accepts liability / Accepts liability in part / Disputes liability

Compensation computed and proposed date of deposit

Insurer, policy and date of intimation

Name of the authorised signatory

Designation of the authorised signatory

DD.MM.YYYY (2)

Inward number of the report

DD.MM.YYYY (3)

DD.MM.YYYY (4)

Date of the report in Part A

Place of the accident

Killed / permanently disabled / injured

Date of death

Compensation for death in Rs

Monthly wages taken for computation

Relevant factor applied

Age of the employee in completed years

Funeral expenses in Rs

Medical expenses in Rs

Interest included in Rs

Total deposited in Rs

Permanent total disablement / permanent partial disablement assessed at Percentage per cent loss of earning capacity

A woman / a person under a legal disability, namely state it

Lump sum compensation in Rs

Amount of liability accepted in Rs

Demand draft number, date and bank / electronic transfer, UTR number and date / the online deposit facility of the competent authority, transaction reference

Payee name required by the competent authority

No advance has been paid. / An advance of Rs Amount of advance on account of compensation was paid on DD.MM.YYYY to Name and relationship of the dependant, against the receipt enclosed. We request that it be deducted from that dependant's share and repaid to us, as the Code provides.

State the grounds, e.g. the monthly wages are Rs __ and not Rs __ as claimed, as shown by the wage register enclosed; the assessment of loss of earning capacity at __ per cent is disputed and a medical examination by a qualified medical practitioner is requested.

E-mail address for notices

Name of the contact person

Designation of the contact person

Telephone number

Receipt for the advance paid to a dependant

Name and code of the employee

Parentage and address of the employee

Date of birth and age proof

Date of joining and mode of engagement

Date, time and place of the accident (2)

Result of the injury

Method and figure of monthly wages

Compensation computed in Rs

Advance paid to a dependant

Insurer and policy number

Dependant 1 name

Dependant 1 relationship

Dependant 1 age

Dependant 1 address

Yes / No (1)

Dependant 1 source

Dependant 2 name

Dependant 2 relationship

Dependant 2 age

Dependant 2 address

Yes / No (2)

Dependant 2 source

Dependant 3 name

Dependant 3 relationship

Dependant 3 age

Dependant 3 address

Yes / No (3)

Dependant 3 source

Dependant 4 name

Dependant 4 relationship

Dependant 4 age

Dependant 4 address

Yes / No (4)

Dependant 4 source

DD.MM.YYYY (5)

DD.MM.YYYY (6)

Name and address of the employee or the dependants

Name of the addressee

Date of the deposit

We paid Rs Amount of advance to Name and relationship of the dependant on DD.MM.YYYY as an advance; the competent authority will deduct it from that person's share. / No advance has been paid.

Half-monthly payment in Rs

Date of the first half-monthly payment

Percentage of loss of earning capacity

Name of the qualified medical practitioner

Paid to your bank account / deposited with the competent authority, who will pay it to you

Date of payment or deposit

Have been / will be

DD.MM.YYYY (7)

Place of the medical examination

Number of the notice

Date of the notice

Date of receipt of the notice

State the grounds, e.g. the deceased was not our employee but an employee of Name of the contractor, whose particulars are below; the death did not arise out of and in the course of employment because state the facts; the deceased was an insured person under Chapter IV and the claim lies with the Employees' State Insurance Corporation

Working paper for the employer's file and the statement that goes with the payment or deposit. Do not use it for an insured person under Chapter IV: that claim lies with the Employees' State Insurance Corporation

Use this working paper when an employee is killed or disabled by an accident or an occupational disease arising out of and in the course of employment and the employee was not an insured person under the ESI chapter of the Code. Report and deposit with the "Report of an accident and deposit of compensation with the competent authority" in this pack. For the statutory notices of the accident itself, use the "Notice of accident or dangerous occurrence" and the "Register of accidents and dangerous occurrences" in the OSH formats, and for an insured person the "Accident report to the Branch Office" in the ESI formats. This format cites Chapter VII by subject; before quoting a section number in a filing, read the bare Code, because many commentaries still reproduce the clause numbers of the 2019 Bill.

Part A. Coverage and route

Question	Answer	Consequence
Is the injured or deceased person an employee of the establishment, including one engaged through a contractor?	[Yes / No]
Was the employee an insured person under Chapter IV (employees' state insurance) on the date of the accident?	[Yes / No]
Did the injury arise out of and in the course of employment?	[Yes / No / Disputed]
Did the accident happen while commuting between residence and the place of employment?	[Commuting / Not commuting]
Result of the injury	[Death / Permanent total disablement / Permanent partial disablement / Temporary disablement]
Did the disablement last more than three days?	[More than three days / Three days or less]
Was the accident directly attributable to drink or drugs, wilful disobedience of a safety order or rule, or wilful removal or disregard of a safety guard?	[Attributable / Not attributable]
Is the injury an occupational disease listed in the Third Schedule?	[Listed occupational disease / Accident]
Route

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