Fill online: Report of an accident and deposit of compensation with the competent authority

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Your details

Name of the establishment

Fills 8 places in the document.

Address of the establishment

Fills 3 places in the document.

Reference number

Fills 2 places in the document.

DD.MM.YYYY (1)

Office and address of the competent authority

Fills 5 places in the document.

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

On the letterhead of the establishment. For an employee who was not an insured person under the ESI chapter. Compute first with the "Employee's compensation computation and statement" in this pack

This format contains the report to the competent authority of an accident causing death or serious bodily injury (Part A), the letter depositing compensation (Part B), the statement of particulars that goes with the deposit (Part C), the letter to the employee or the dependants (Part D) and the reply to a notice from the competent authority about a fatal accident (Part E). The statutory notice of the accident under the OSH Code is separate and comes first: use the "Notice of accident or dangerous occurrence" and make the entry in the "Register of accidents and dangerous occurrences". For an insured person, use the "Accident report to the Branch Office" instead of this format. The competent authority is the authority appointed by the appropriate Government for the area under Chapter VII; where the State has not yet notified one, the Commissioner for Employees' Compensation for the area continues to receive these papers in practice. Confirm the office before filing.

Part A. Report of an accident causing death or serious bodily injury

The repealed Employee's Compensation Act 1923 (section 10B) required this report within seven days of the death or serious bodily injury wherever another law required notice of the accident to an authority, as the OSH Code does. Check the period and form prescribed under the Code by the appropriate Government and send the report within seven days unless a shorter period is prescribed. Serious bodily injury, in substance, is an injury involving, or likely to involve, the permanent loss of the use of, or permanent injury to, a limb, the permanent loss of or injury to sight or hearing, the fracture of a limb, or the enforced absence of the injured person from work for more than twenty days.

[Name of the establishment]
[Address of the establishment]

Ref.: [Reference number] Date: [DD.MM.YYYY (1)]

To
The Competent Authority under Chapter VII of the Code on Social Security 2020
[Office and address of the competent authority]

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