CAP.282|
Employees' Compensation Regulations
[1987 Ed.
Notice is hereby given that (2)
on the (3)
...... day of
19............. was found to be suffering from
the following occupational disease
believed to be due to his employment by you upon the
following work (4),
resulting in the death/partial/total incapacity of a permanent/temporary nature's) of the employee.
And notice is hereby further given that in consequence thereof compensation is claimed from you.
Dated this
day of
......
..
19...........
(5)
(1) Name and address of the employer or principal contractor.
(2) Full name and address of the employee.
(3) Date upon which disease is said to have been discovered.
State nature of the work which is said to have caused the occupational disease.
(4)
(5) Delete whichever is inapplicable.
(6) Signature, name and address of person giving the notice.
逕啓者:(1)
表格一甲
僱員賠償條例(香港法例第二八二章) 因患職業病而致喪失工作能力或死亡通知書 (由僱員填報或代僱員填報)
[規例第三條]
# (2)............
4...................
此病相信係因受僱於台端從事(3)
局部 之工作而引起者。該僱員現已因病而致(4)死亡喪失————工作能力,特向
永久 ̇全部 台端通知要求賠償。此致
暫時
(5)..........
一九
年月日
(1) 僱員詳細姓名及地址
(2) 所稱發覺患病日期
(3) 說明所稱引致該職業病之工作性質
(4) 將不適用者刪去
(5) 僱主或總承判商姓名及地址
(6) 填報者之簽名、姓名及地址
(6)......
A 4
[Subsidiary]
CAP.282|
Employees' Compensation Regulations
[1987 Ed.
Notice is hereby given that (2)
on the (3)
...... day of
19............. was found to be suffering from
the following occupational disease
believed to be due to his employment by you upon the
following work (4),
resulting in the death/partial/total incapacity of a permanent/temporary/nature's) of the employee.
And notice is hereby further given that in consequence thereof compensation is claimed from you.
Dated this
day of
......
..
19...........
(5)
(1)
Name and address of the employer or principal contractor.
(2)
Full name and address of the employee.
(3) Date upon which disease is said to have been discovered.
State nature of the work which is said to have caused the occupational disease.
(4)
(5)
Delete whichever is inapplicable.
(6)
Signature, name and address of person giving the notice.
逕啓者:(1)
表格一甲
僱員賠償條例(香港法例第二八二章 ) 因患職業病而致喪失工作能力或死亡通知書 (由僱員填報或代僱員填報)
[規例第三條
# (2)............
4...................BRALATTEREN :
婴
此病相信係因受僱於台端從事(3)
局部 之工作而引起者。該僱員現已因病而致(4)死亡喪失————工作能力,特向
永久 ̇全部 台端通知要求賠償。此致
暫時
(5)..........
一九
年月日
(1) 僱員詳細姓名及地址
(2) 所稱發覺患病日期
(3)說明所稱引致該職業病之工作性質
(4) 將不適用者删去
(5) 僱主或總承判商姓名及地址
(6) 填報者之簽名、姓名及地址
(6)......
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