CAP.282]
Employees' Compensation Regulations
[1987 Ed.
Name of next-of-kin
近親姓名
Address of next-of-kin
近親地址
Relationship with employee
與僱員關係
Telephone Number
電話號碼
Average number of days per week/month* worked
每週/月平均工作日數
Paid rest day?
Yes/No*
休息日是否有薪?
The total earnings for the month immediately preceding the date of accident were $
該僱員於意外發生當日之前一個月之總收入
0
Details are as follows:----
詳情列下:
Basic salary/wages
基本薪金/工資
$...
*Regular overtime
經常性加班
$..
每日/週/月
$..
*Regular tips/commission
經常性小費/佣金
*Additional allowance or bonus of a constant nature
固定性之額外津貼或獎金
$..
每日/週/月
*Value of free food provided by employer
僱主提供之免費食物價值
*Value of free accommodation provided by employer
僱主提供之免費住宿價值
...
每日/週/月
元
每日/週/月
元
每日/週/月
元
每日/週/月
元
The total average monthly earnings of the employee for the past 12 months (or total period of employment,
if less than 12 months) preceding the accident were $
在意外發生前之十二個月內(如不足十二個月，則以整段僱傭期間計)之每月平均收入
Was the employer insured against liabilities under the Employees' Compensation Ordinance
at the time of accident?
發生意外時，僱主是否已依照僱員補償條例購有賠償責任保險?
Name and address of insurance company
保險公司名稱及地址
Yes/No*
Policy Number
保單號碼
Number of Business Registration Certificate of the employing company (if such certificate is not available, the identity card number of the employer)
僱用公司之商業登記證號碼(如無，則填寫僱主身份證號碼)
I declare that the information given above is, to the best of my knowledge, true and accurate.
聲明本人所知，上述所提供之資料正確無誤
* Delete whichever is not applicable
刪除不適用者
Signature:
簽署:
Name (in block letters):
姓名(正楷):
Position: *Sole proprietor/Partner/Manager/Officer
職位:
Date:
日期:
(Chop of company)
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