ET. Amount of compensation agreed upon (4)
JOGO-------KATIKA+
(a) Amount payable in a lump sum ...............S-FUN-+++++/.................................... (b) Amount and period of periodical payments (e) To whom payable
+ALIYENİYYE
Date of the Commissioner of Labour's approval of the agreement as to compensation (5)
7.
8.
Any other information
1.
do solemnaly and sincerely declare that the foregoing particulars stated are true, and I make this solemn declaration conscientiously believing the same to be true and by virtue of the provisions of the Statutory Declaration Act, 1836.
Made and subscribed this before me at ......................
(1)
(3)
(0
Signature of applicant.
day of
19......
Justice of the Peace, Notary Public, or Commissioner for Oatha.
Full detaily of the nature of the work and duties on which the workman WAL employed at the date of the accident.
Give full detall and state whether incapacity in total or partial, parma TNI KLİ Lemporar If partial, the degree, and," | "temporary, the" perlod "of metuat one estimated løsaapacity muse be given.
The monthly curang muk be stated, speeltying the value of food, foel, or qarters if the worktown has been deprivod thereof na a result of the accident. (See section 8 and 10 of the Ordinance).
Copy of apprennent must be attached.
(6) Copy of Commisalonar of Labour's Bignideation of approval must be atlasbød.
Treg. 8.
PART IL
If payments have been made in respect of an accident by an employer (other than payments for which he has been or is to be reimbursed “bu an insurer) the following form must be filled wp. If no such paymentu have been made the following form must not be filled up, as the necessary returns are made by the insurer.
A. CASES IN WHICH COMPENSATION WAS PAID FOR DEATH.
(Compensation paid in respect of previous incapacity should be included in Table B).
Coses where compensation |
(including medical or burial [ any) WAS
expenses, paid
No. of cases in which compensa- tion was paid
during 19...
Total amount of compensation paid during 19......
B. CASES IN WHICH COMPENSATION WAS PAID FOR INCAPACITY.
Cases continued from pre-
vious yearS ..........NOBRO
Cases in which the first payment of compensation was made during 19...............
No. of cases in which compensa- tion was paid
during 19.1
Total amount of compensation paid during 19......
lunap summ paymenta
periodical payments
SECOND SCHEDULE,
Form of return by employer to be made to the Commissioner of Labour, Hong Kong.
PART I
(1) Have you bean insured for the whole of 19............... (or the whole period within that year during which work- men were employed by you) and in respect of your whole liability under the Workmen's Compensation Ordinance, 19531
state the name of the insurer.
If Bo.
(2) If you have not been insured at any time during 19.............. or have only been parti- ally insured, have you made any payments for compensation during the year?
Name of Employer
Address
Signed
(Secretary or Manager).
TOTAL
+++TE
Form of return by Insurer.
A. CASES IN WHICH COMPENSATION WAS PAID FOR DEATH. (Compensation paid in respect of previous incapacity should be
included in Table B).
Casea where compensation
(including medical or burial expenses, if any)
paid
WAL
No. of cases in which compensa- tion was paid during 19.....
Total amount of comperuation paid during 19...+++
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