The Oriental Insurance Company Limited
Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002

EMPLOYERS LIABILITY CLAIM FORM

PARTICULARS OF ACIDENT TO BE FURNISHED BY THE EMPLOYER
These questions are to be answered whether or not a claim from the injured person has been made or is
anticipated .
The Insurer does not admit liability by the issue of this form
NB- If any details of information are not readily available PLEASE DO NOT DELAY DESPATCH of this
form but send supplementary advices later.
PART-I : THE EMPLOYER
1. Name of Policy holder
2. Business
3. Address (and nearest railway station)
4. District
____________________5. Policy No._____________
PART-II: THE INJURED PERSON
6. Name
7. Religion or caste
10. Local Address
11. Mofusil address
12. Occupation in which injured person is
employed
13. Was the injured person actually
Working when the accident occurred?
14. Is the Injured person in your direct
employ ?(if not, give name and address
of contractor and nature of contract)
15. Name of the Hospital taken to
16. State whether still in hospital or when
discharged.
18. State whether still in hospital or when
discharged
19. State nature of injury, regions injured
and whether left or right.
20. Did injured person actually cease work,
and if so, on what date?
21. Has injured person resumed duty since
and if so, on what date?
22. What is the probable period of
disablement (approximate)?
23. Was the injured person free from
physical infirmity at the time of the
accident? If not, give particulars.
_____8. Age_______ 9. Sex____________________
_______________17.In or out-patient____________
Issuing
Office
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PART- III
24. Date of Accident
25. Did the accident occur actually within your
work premises? If not, where did it occur?
26. On what date did you receive notice of
accident and from whom? If in writing please
attach to this form
27. Are you satisfied injured person met with a
bonafide accident of employment?
28. How exactly did the accident occur?
29. If accident due to machinery, statea)
whether it was fenced or guarded
b) was it being cleaned whilst in motion
30. Was injured person under the influence of
drink or drugs at the time of the accident?
31. Was he guilty of any misconduct or
disobedience to order or rules? I so, please
give full particulars.
32. State through whose neglect if any, it occurred
33. State the names of any two persons who
witnessed the accident.
34. Give name of over looker or person in
superintendence.
Time ____________Place______________
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The above replies are accurate to the best of my knowledge and belief:
Date__________ Signature of Employer_________________
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STATEMENT OF INJURED PERSON’S EARNINGS
Statement of wages which have fallen due for payment to________________________________
__________________in the employ of _____________________________________ for 12 months period
to the date of his accident or wages earned during such shorter period as he may have been in the
employor’s service.
Note: The object of this part of the form is to ascertain the extra average monthly earnings of the injured
person. It is essential that it should be carefully and correctly filled in, if the injured person has been in
service for less than twelve months his date of entry into service is essential. So also if he was absent
continuously for more than 14 days (within 12 months) between the date of his entry into service and that
of accident, then the period of service should be counted from the date of resumption of duty.
Date on which the injured person first entered service________________20
Date on which the injured person resumed duty after a continuous absence of more that 14
days______________20
Months and Year Wages earned
(Including overtime)
Value of bonus*
food subsidy. If
any free quarters
and any other
allowance etc.
Absences**
1 Rs. P. Rs. P.
2
3
4
5
6
7
8
9
10
11
12
Total earnings in the period from…………………..
Total Including All Allowances Rs…..
MONTHLY AVERAGE WAGES ________RS._______
SPECIAL NOTICES
If the worker’s period of service was less than one month, give the
Average Monthly wages a Workman employed on similar work. Rs._______________
Please state the exact nature of the allowance and or bonus…..
In column “absences” please give date of going on leave or beginning of the period of absence and also
date of subsequent resumption of work.
The above statement of earnings, etc., is to the best of my knowledge and belief, accurate.
Date 20 Signature of Employer
(Add below any additional information available regarding the accident)
Signature of Employer