1964_EMPLOYEES__COMPENSATION_REGULATIONS — Page 2

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[Subsidiary]

Forms. Schedule.

L.N. 208/83.

CAP. 282] Employees' Compensation Regulations

[1987 Ed.

7. The forms contained in the Schedule or forms to the like effect shall be used with such variations and modifications as the circumstances may require.

To: (

SCHEDULE

FORM 1

EMPLOYEES' COMPENSATION ORDINANCE

(Chapter 282)

NOTICE OF ACCIDENT BY OR ON BEHALF OF EMPLOYEE

Notice is hereby given that (2)

on the (3)

day of

19............ at (4)

met with an accident causing his (5)

and that the cause of the injury/death was (6)

[reg. 7.]

[reg. 3.]

And notice is hereby further given that in consequence thereof compensation is claimed from you.

Dated this

day of

(7)

(1)

Name and address of the employer or principal contractor.

(2)

Full name and address of the employee.

(3)

Date of accident.

(4)

Place of the accident.

(5)

Whether disablement or death.

(6)

State in plain and ordinary terms the cause of the injury or death.

(7) Signature and address of person giving the notice.

19...........