1969-HKRS30-16-29_Part05 — Page 7

Address

Occupation

Duration of employment

from

ta

The wages of the workman at the time of accident were $......ng++{" day/week/month.*

For the preceding twelve months or total period of employment, if less than twelve months, the following additional information is provided:

Average wager

Average wages for regular

overtime worked

$.

-/day/week/month.*

/day/week/month."

Additional allowance or bonus

of constant nature

$..........

............................................../day/week/month.*

Disease suffering from

Total:

$.

./day/week/month.*

Date of onset of the occupations] disease

Was free food provided by the employer?

Was free accommodation provided by the employer'!

Yes/No2

Yes/No*

Types of work attributed to the occupational disease:-

The occupational disease resulted in death/partial/total incapacity of a permanent/temporary* mature

Was the employer insured against liabilities under the Workmen's Com- pensation Ordinance?

Yes/No

Name of insurance company

Policy Number

Name of employer

Address

Telephone Number

If accident resulted in death, Pelice not notified/notified" at

Name of next-of-kin

Address

Station.

Relationship

I intend/do not intend" to dispute the workman's claim to compensation on the following grounds:-

(Chop of company)

* Delete whichever is mal applicable.

Signature

Position

Date

30th June 1970.

R.My. I desterington

Commissioner of Labour.

Explanatory Note.

(This Note is not part of the regulations, but is intended to indicate their general purport).

These regulations prescribe new forms of notices to be given to the Commissioner of Labour by employers, in respect of their employees, of accidents resulting in incapacity or death or of incapacity or death due to an occupational disease.