Form XI — Notice of Accident or Dangerous Occurrence

Rule: Rule 7(1), 7(2) · Signed by: Occupier, Safety Officer · Under: OSH & Working Conditions (Central) Rules 2026

What the form records

E.S.I.C. Employer's Code number
E.S.I.C. Insurance Number of the injured person
Name of employer
Address of works / premises where the accident or dangerous Occurrence took place
Nature of industry and LIN of the establishment
Branch or department and Exact place where the accident or dangerous occurrence took place
Name and address of the injured person
Gender
Age (at the last birthday)
Occupation of the injured person
Local E.S.I.C. Office to which the injured person is attached
Date, shift and hour of accident or dangerous occurrence
Hour at which the injured person started work on the day of accident or dangerous occurrence
Whether wages in full or part are payable to them for the day of the accident or dangerous occurrence
Cause or nature of accident or dangerous occurrence
If caused by machinery - Give the name of machine and the part causing the accident or dangerous occurrence
State whether it was moved by mechanical power at the time of accident or dangerous occurrence
State exactly what the injured person was doing at the time of accident or dangerous occurrence
In your opinion, was the injured person at the time of accident or dangerous occurrence acting in contravention of provisions of any law applicable to them; or acting in contravention of any orders given by or on behalf of their employer; or acting without instructions from their employer?
In case reply to (d) (i), (ii) or (iii) is in the affirmative, state whether the act was done for the purpose of and in connection with the employer's trade or business
In case the accident took place while travelling in employer's transport - whether the injured person was travelling as a passenger to or from their place of works
Whether the injured person was travelling with the express or implied permission of their employer
Whether the transport is being operated by or on behalf of the employer or some other person by whom it is provided in pursuance of arrangements made with the employer
Whether the vehicle is being/not being operated in the ordinary course of public transport service
In case the accident took place while meeting emergency - its nature
Whether the injured person at the time of accident or dangerous occurrence was employed for the purpose of their employer's trade or business in or about the premises at which the accident or dangerous occurrence took place
Describe briefly how the accident or dangerous occurrence took place
Names and addresses of witnesses
Nature and extent of injury (e.g. fatal, loss of finger, fracture of leg, scald, scratch followed by sepsis, etc.)
Location of injury (e.g. right leg, left hand, left eye, etc.)
If the accident or dangerous occurrence was not fatal, state whether the injured person was disabled for more than 48 hours
Date and time when the injured person returned to work
Physician, dispensary or hospital from whom or which the injured person received or is receiving treatment
Name of dispensary/panel doctor elected by the injured person
Has the injured person died?
If so, date of death
Signature and Name and Designation of owner/ employer /manager/agent
Date of dispatch of report
Place

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

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