1964_EMPLOYEES__COMPENSATION_REGULATIONS — Page 10

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[Subsidiary]

CAP. 282] Employees' Compensation Regulations

I,

[1987 Ed.

do solemnly and sincerely declare that the foregoing particulars stated are true and I make this solemn declaration con- scientiously believing the same to be true and by virtue of the provisions of the Oaths and Declarations Ordinance.

Signature of applicant.

Declared at

in Hong Kong this

day of

19

Before me,

Justice of the Peace, Notary Public, or Commissioner for Oaths.

(1) Full details of the nature of the work and duties on which the employee was employed at the date of the

accident.

(2) Give full details and state whether incapacity is total or partial, permanent or temporary. If partial, the

degree, and, if temporary, the period of actual or estimated incapacity must be given.

(3) The monthly earnings must be stated, specifying the value of food, fuel or quarters if the employee has been

deprived thereof as a result of the accident. (See sections 3 and 11 of the Ordinance.)

(4) Copy of certificate or agreement as determined or approved by the Commissioner for Labour must be

attached.

表格三

僱員賠償條例(香港法例第二八二章 )

僱主所付賠償額之證明書或協議書細則

【規例第五條】

(本表格必須由要求將證明書或協議書轉為法院命令之一方填寫及 提交法院經歷司。)

(一) 僱主姓名、地址及經營之業務..

(二)(甲) 僱員姓名及地址...

(乙) 職業(註一)

(75) FR........

(丁) 性別

(戊) 僱員因此宗意外事件從僱主方面收取之賠償額(如已收取者)..

(三)(甲) 意外發生日期

(乙) 意外發生原因

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