1964_EMPLOYEES__COMPENSATION_REGULATIONS — Page 8

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[Subsidiary]

CAP. 282] Employees' Compensation Regulations

[1987 Ed.

The total earnings for the month immediately preceding the date of the employee's incapacity or death were $

癲歸於喪失工作能力或死亡當日之前一個月之總收入蹣

Details are as follows:-

#WF:

ཡ

Basic salary/wages

底薪

*Regular overtime

* # # 2 ANIKĦS

*Regular tips/commission

*###24 R/M&

*Additional allowance or bonus of a constant nature

**** 2 *ADERES

*Value of free food provided by employer

*Value of free accommodation provided by employer

*儷主免費供齡之住宿之價值

I

/day/week/month*

#0/1/*.

..I

$...

毎日/週/月*

$.

$Q/8/A*..

/day/week/month*

/day/week/month*

/day/week/month*

QB/B/A*..

元

/day/week/month*

#B/0/*.

/day/week/month*

$8/8/A*.

The total average monthly earnings of the employee for the past 12 months (or total period of employment.

if less than 12 months) preceding the employee's incapacity or death were $.

在催錢喪失工作能力或死亡前之十二個月内(如不足十二個月,顛以整段期間計)之每月平均收入躍

Was the employer insured against liabilities under the Employees' Compensation Ordinance

at the time of the employee's incapacity or death?

於僱疎喪失工作能力或死亡時、佩主是否已依照儺賠償條例購有賠償責任保險?

Name and address of insurance company

Yes/No*

£/5*

Policy Number

Number of Business Registration Certificate of the employing company (if such certificate is not available, the identity card number of the employer)

權用公司之商業登記證號碼(如無此證,請填寫僱主身份證號碼)

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

本人類/不*對該僱員之賠償要求提出反駁,理由如下:

I declare that the information given above is, to the best of my knowledge, true and accurate. 慈戆明據本人所知,上述所報之資料,皆蕻礎。

Signature:

簽署:

Name (in block letters):

#% (###):

Position: *Sole proprietor/Partner/Manager(Officer 職位: ✰ * / **/**/± #

Date:

(Chop of company)

公司蓋印

日期:

• Delete whichever is not applicable

* ##58427GME