1964_EMPLOYEES__COMPENSATION_(RULES_OF_COURT)_RULES — Page 10

B 10

CAP. 282]

Employees' Compensation (Rules of

[1983 Ed.

Court) Rules

[Subsidiary]

PARTICULARS

(1) Date of birth or age of the applicant at the date of the accident

(2) Nature of employment of the applicant at the time of the accident

(3) Date and place of accident, nature of work on which the applicant was then

engaged and nature of accident and cause of injury

(4) Nature of injury

(5) Particulars of incapacity and/or of constant attention

(6) Monthly earnings of the applicant from employment with the respondent--

(a) for the month immediately preceding the accident

(b) on average during the 12 months (or any lesser period of employment

with the employer) prior to the accident

(7) If temporary incapacity pursuant to section 10 of the Ordinance is alleged, monthly earnings (if any) which the applicant is earning or is capable of earning (if

known) during the period of temporary incapacity

are

(8) Amount claimed as compensation

(9) Date of giving notice of accident to respondent

(10) If notice not given, reason for omission to give such notice

The name and address of the applicant or his solicitor are-

Of the applicant

Of his solicitor

The name and address of the respondent(s) to be served with this application

Dated this

day of

19

* Delete as required.

Applicant Solicitor for the Applicant

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