FORM 11

ACCIDENT BOOK
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 66)
Details of Injury What Name, Signature Name, Remarks,

Shift, department and Occupation of the employee

exactly occupa- and address if any
was the tion, designati and
injured address on of the occupatio
person and person n of two
Name and Address of Injured Person

doing at signature who witnesses

the time or the makes the
of thumb entry in
accident impressio the
n of the Accident
person(s) Book
giving
Time of Notice
Date of Notice

Insurance No.
notice
Sl. No.

Age
Sex

Cause Nature Date Time Place

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

No Accident in the Month of JAN -2018

Signature of the Employer

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