Employee State Insurance (General)

Regulations
Form 11
(Regulation 66)

Accident Book

Serial No. Date of Time of Name and Sex Age Insurance Shift,
Notice Notice address of No. department
the injured and
person occupation
of
employee

INJURY What Name, Signature Name, Remarks

exactly occupation, and address , if any
Cause Nature Date Time Place
was the address and designatio and
of
injured signature or n of the occupatio
injury
person the thumb person n of two
doing impression who witnesses
at the of the makes the
time of persons entry in the
injury? giving notice Accident
Book