WORKMEN'S COMPENSATION Return relating to period from .to 31st December, 200.. State ... District . Town or Village...

Post Office . Name of establishment.. Nature of Work.

(To be omitted in case of railways)

Average numbers employed per day Adults Minors .. Accident Number of cases of injuries in respect of which final compensation has been paid during the year Occupational Diseases Amount of Compensation paid

Amount of Compensation paid

Number of cases of diseases in respect of which final compensation has been paid during the year Permanent disablement

Death Permanent Temporary Death Permanent Temporary Nature of Death disablement disablement disablement disablement diseases Rs. Rs. Rs. Adult Minors

Temporary disablement

Death Permanent disablement Rs. Rs.

Temporary disablement Rs.

Dated ,200.

(Signed). (Designation).

FORM EE [See rule 11] Report of Fatal Accidents To,

Sir, 1. I have the honour to submit the following report of an accident which occurred on ...(dated), at .here enter details of premises and which resulted in the death of the .. (workman/workmen) of whose particulars are given in the statement annexed. workman The circumstances attending the death of the ___________were as under. workmen a. Time of the accident; b. Place where the accident occurred; c. Manner in which deceased was/were employed at the time; d. Cause of the accident; e. Any other relevant particulars; I have, etc.

2.

Signature and designation of person making the report. Statement Name Sex Age Nature of Employment Full Postal Address