Form 25 — Report of Accident or Dangerous Occurrence Resulting in Death or Bodily Injury

Rule: Rule 121(3) · Signed by: Manager · Under: Factories Act 1948 / Model Factories Rules 2020

Notice to Inspector of any accident causing death or injury disabling worker >48 hrs. Filed within 24-48 hrs of occurrence. Signed by Manager; FMO contributes injury details via Injury Register.

What the form records

• ESIC employer code + insurance no. of injured
• Occupier/factory name
• Address where accident took place
• Nature of industry
• Branch/department + exact place
• Injured person name + address
• Sex, age, occupation
• Local ESIC office
• Date, shift, hour of accident
• Hour injured started work that day
• Wages payable for the day
• Cause/nature of accident
• If caused by machinery: machine + part + powered or not
• What injured was doing
• Whether injured was acting in contravention of law/orders/instructions
• If during travel: passenger to/from work? employer's transport?
• If during emergency: state nature
• Brief description of how it happened
• Witnesses (names + addresses)
• Nature + extent of injury
• Location of injury (body part)
• Whether disabled >48 hrs + return-to-work date
• Treating physician/dispensary
• Has injured died? Date of death
• Signature of manager + date despatched

This page opens the blank statutory form in MedFactory, ready to fill, save and print. See the Form 25 reference page for the rule and signatory detail.

MedFactory — Occupational Health Centre software for Indian factories