1969-HKRS30-16-29_Part05 — Page 6

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