FORM B
[Rule 4]

To
Sir,
The report about an accident which occurred on at (here enter details of premises) and which resulted in death/disablement of the workmen is furnished as given below: -
1.
(a) Name of the workman
(b) Sex, age and monthly wage
(c) Nature of employment
(d) Name of the employer
(e) Full postal address of the workman/dependents (local and permanent both).
(f) Full postal address of the factory/establishment where its registered office is located.
2. The circumstances leading to death/disablement of the workman:-
(a) Time of the accident
(b) Place where the accident occurred
(c) Manner in which deceased was/were employed at that time
(d) Cause of the accident
3. The amount of money deposited by The employer with the Commissioner under section 8
4.
(a) Details of compensation paid, if any
(b) Particulars of money invested for the benefit of dependents of deceased workman
5. Documents forwarded (in original) as under: -
(a) Death certificate
(b) Disablement certificate from the competent medical authority
(c) Receipt for deposit of compensation by the employer
(d) Statement of disbursement
(e) Receipt of compensation from the workman/dependents
(f) Memorandum of agreement, if any.
Dated : ______________