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

Form-24A

(To Be Filled By Factory Occupier or Manager)

Name of Factory

Factory Address

Factory Pincode

District (Factory)

Taluka (Factory)

Name of Occupier

LIN - Labour Identification Number (Optional)

Employer's ESIC Registration Number (If available)

Occupier's Email

Occupier's Mobile No

Occupier Address

Occupier Pincode

District of the occupier

Taluka of the occupier

Name of Manager

Manager Address

Manager Pincode

District of the Manager

Taluka of the Manager

Nature of Industry

Name of Branch or Department

Exact place where the the dangerous occurance took place

Date and hour of occurance

Date

Time

Nature of dangerous occurance (State exactly what happened)

Name of Contact Person

Mobile No of Contact Person

Designation of Contact Person