Directorate of Industrial Safety and Health, Maharashtra State :: औद्योगिक सुरक्षा व आरोग्य संचालनालय, महाराष्ट्र राज्य

Name of Occupier

Occupier’s Registration No./License No

LIN - Labour Identification Number (Optional)

Employer's ESIC Registration Number (If available)

Occupier's Email

Occupier's Mobile No

Name and Address of the factory

Pincode

District (Factory)

Taluka (Factory)

Nature of Industry

Name of Department

Department shift hours (if any)

Exact place where the accident happened

Name of Contact Person

Mobile No of Contact Person

Designation of Contact Person

Name of injured person

Insurance Number

Address of injured person

Gender of injured person

Age of Injured Person

Occupation of injured person

Local office to which attached

Date and hour of accident

Date

Time

Hour at which he started work on the day of accident

Whether wages in full or part are payable to him for the day of his accident

(a) If caused by machinery –

Yes

No

(i) Give name of the machine and part causing the accident

(ii) State whether it was moved by mechanical power at that time

Yes

No

State exactly what the injured person was doing at that time

(i) Acting in contravention of the provisions of any law applicable to him

Yes

No

(ii) Acting in contravention of any orders given by or on behalf of occupier

Yes

No

(iii) Acting without instructions from his occupier

Yes

No

If reply to clauses (i), (ii), or (iii) of clause (c) is affirmative, state whether the act was done for the purpose of and in connection with the occupier’s trade or business

(i) The injured person was travelling as a passenger to or from his place of work

Yes

No

(ii) The injured person was travelling with the express or implied permission of the occupier

Yes

No

(iii) The transport is being operated by or on behalf of the occupier or some other person by whom it is provided in pursuance of arrangements made with the occupier

Yes

No

(iv) The vehicle was being/not operated in the ordinary course of public transport

Yes

No

(i) Its nature

(ii)Whether the injured person at the time of accident was employed for the purpose of his occupier’s trade or business in or about the premises at which the accident took place.

Yes

No

Describe briefly how the accident occurred.

Name of witness (1)

Address of witness (1)

Name of witness (2)

Address of witness (2)

(a) Nature and extent of injury (e.g.fatal, loss of figures, fracture of leg, scald etc. Fracture of leg

(b) Location of injury (right leg, left hand or left eye etc.)

( c ) (i) If the accident is not fatal state whether the injured person has returned to work

Yes

No

(ii) If so, date and hour or return to work

Date

Time

(a) Physician, dispensary or hospital from whom or where the injured person received or is receiving treatment

(b) Name of dispensary / panel doctor elected by the injured person

Has injured person died?

Yes

No

If so, date of death

Date

Form-24

Accident Reporting for Factories

Information for Injured / Dead Person No - 1

Cause of accident

In your opinion, was the injured person at the time of accident –

If the accident happened while travelling by availing of the transport facility provided by the occupier, state whether

If the accident happened while meeting emergency State