Form XI — Notice of Accident or Dangerous Occurrence

Form XI of the OSH & Working Conditions (Central) Rules 2026, prescribed under Rule 7(1), 7(2).

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