CAP. 282] Employees' Compensation Regulations
[1987 Ed.
The total earnings for the month immediately preceding the date of the employee's incapacity or death were $
Details are as follows:-
Basic salary/wages
*Regular overtime
*Regular tips/commission
*Additional allowance or bonus of a constant nature
*Value of free food provided by employer
*Value of free accommodation provided by employer
$.../day/week/month*
$.../day/week/month*
$.../day/week/month*
$.../day/week/month*
$.../day/week/month*
$.../day/week/month*
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 employee's incapacity or death were $.
Was the employer insured against liabilities under the Employees' Compensation Ordinance at the time of the employee's incapacity or death?
Yes/No*
Name and address of insurance company
Policy Number
Number of Business Registration Certificate of the employing company (if such certificate is not available, the identity card number of the employer)
I intend/do not intend to dispute the employee's claim to compensation on the following grounds:-
I declare that the information given above is, to the best of my knowledge, true and accurate.
Signature:
Name (in block letters):
Position: *Sole proprietor/Partner/Manager/Officer
Date:
(Chop of company)
* Delete whichever is not applicable