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in

EMPLOYEES’ STATE INSURANCE CORPORATION

REG. FORM -11

ACCIDENT BOOK
(Regulation 66)

Sl. Date of Time of Name & Address of Sex Age Insurance Shift, department Details of Injury
No. Notice Notice Injured Person No. & Occupation of Cause Nature Date Time Place
the employee
1 2 3 4 5 6 7 8 9 10 11 12 13

What exactly was the injured
person doing at the time of
accident
14
Name, Occupation address &
signature or the thumb
impression of the person(s)
giving notice
15
Signature and designation of Name, address & Occupation Remarks, if any
the person who makes the of two witnesses
entry in the Accident Book
16 17 18