Nature of injury
2
Result of injury-Injury/Death"
Describe in detail how the accident happened
Place of injury
The wages of the workman at the time of accident were $.............. day/week/month.*
For the preceding twelve months or total period of employment, if less that twelve months, the following additional information is provided:
Average wages
Average wages for regular
overtime worked
Additional allowance or bonus
........./day/week/month.*
./day/week/month.“
of constant nature
『,--༥༡-------- ད ་ ད ༥ ས ད - ཐ - /day/week/month.* ./day/week/month.”
Total:
S.
Was free food provided by the employer?
Was free accommodation provided by the employer?
Yes/No* Yes/No
Was the employer insured against liabilities under the Workmen's Com- pensation Ordinance?
Yes/No
Policy Number
If injury is due to machinery, state:
Type of machine
Name of insurance company
Was the machinery power-driven
Yes/No*
Part causing Injury
Was the machinery in motion
Yes/No*
Name of employer
Address
(Chop of company)
Signature
Position
Date
* Delete whichever is not applicable.
Telephone Number
If accident resulted in death, Police not notified/notified" at
Name of next-of-kin
Address
Station.
Relationship
FORM 24.
(reg. 4.]
Workmen's COMPENSATION OrdinancE-
(Chapter 283).
Section 15,
Notice by Emplayer of the Death or incapacity of a Workman due to Occupational Disease.
(To be completed and returned in duplicate to the Labour Department within 7 days of the incapacity or death),
To the Commissioner of Labour, Hồng Kông.
Name of injured workman (Surname first)
Sex
Age
Identity Card Number