Rule Form XI Form XI
- Chapter
- Annexures · Forms and Appendices
- Text as on
- As notified 08 May 2026
FORM-XI (See rule 7(1) and rule 7(2)) NOTICE OF ACCIDENT OR DANGEROUS OCCURRENCE
E.S.I.C. Employer's CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) number: E.S.I.C. Insurance
Number of the injured person :
1. Name of employer :
2. Address of
works / premises
where the accident
or dangerous
Occurrence took place :
3. Nature of industry and LIN of the establishmen t:
4. Branch or department and
Exact place where the accident
or dangerous occurrence took
place :
5. Name and address of the injured person :
6. (a) Gender :
(b) Age (at the last birthday) :
(c) Occupation of the injured person :
7. Local E.S.I.C. Office to which the
injured person is attached :
8. Date, shift and hour of accident
or dangerous occurrence :
9. (a) Hour at which the
injured person started
work on the day of
accident or dangerous occurrence :
(b) Whether wages in full or part are payable to them for the day of the accident or dangerous occurrence
:
10. (a) Cause or nature of accident
or dangerous occurrence :
(b) If caused by machinery-
(i) Give the name
of machine
and the part
causing the
accident or
dangerous
occurrence :
(ii) State whether
it was moved
by mechanical
power at the
time of
accident or
dangerous
occurrence :
(c) State exactly what the injured person was doing at the time of accident or dangerous occurrence :
(d) In your opinion, was the injured person at the time of accident or dangerous occurrence -
(i) acting in contravention of provisions of any law applicable to them; or
(ii) acting in contravention of any orders given by or on behalf of their employer; or
(iii) acting without instructions from their employer?
(e) In case reply to (d)
(i), (ii) or (iii)is in the
affirmative , state : whether the act was done for the purpose of : and in connection with the employer's trade or business.
11. In case the accident or dangerous occurrence took place while travelling in the employer's transport, state whether-
(a) the injured person was travellin g as a passenge r to or from their place of works;
(b)the injured person was travelling with the express or
implied permission
of their employer; :
(c) the transport is being operated
by or on behalf of the
employer or some
other person by whom
it is provided in
pursuance of
arrangements made
with
the employer; and :
(d)the vehicle is
being/not being
operated in the
ordinary course
of public transport service :
12. In case the accident or dangerous occurrence took place while meeting emergency, state-
(a)its nature; and
(b) whether the injured
person at the time of accident or dangerous occurrence was employed for the purpose of their employer's trade or business in or about the
premises at which the accident or dangerous occurrence took place.
:
13. Describe briefly how the accident or
dangerous occurrence took place :
14. Names and addresses of
witnesses : (1)
(2)
15. (a) Nature and
extent of injury(e.g.
fatal, loss of finger,
fracture of leg,
scald, scratch
followed by sepsis, etc.) :
(b) Location of injury (e.g. right leg, left hand, left eye, etc.)
16. (a) If the accident or dangerous
occurrence was not fatal, state whether the injured person
was disabled for more than 48 hours :
(b) date and time when the injured person returned to work: :
17. (a) Physician, dispensary or
hospital from whom or which
the injured person
received or is receiving treatment :
(b) Name of dispensary/panel doctor
elected by the injured person :
18. (a) Has the injured person died ? :
(b) If so, date of death :
I certify that to the best of my knowledge and belief the above particulars are correct in every respect.
Signature and Name and Designation of owner/ employer /manager/agent
Date of dispatch of report : Place: