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FORM 16 [ REGULATION 68 ]
ACCIDENT REPORT FROM EMPLOYER
5c Exact place of accident his left foot second finger and cut the entire
finger.
6 Name of Insured person
2
9a Sex
9b Age ( Last birthday) 17a Nature and extent of injury (e.g.fatal, loss of
finger, fracture of leg, scald etc.)
9c Occupation
9d Branch office 17b Location of injury (right.left leg, hand or eye etc.)
(ii)
(b) State exactly what the injured person was doing at that time.
* (d) Incase reply to C(1),(2) or (3) is YES, state wether the act was done
for the purpose of and in connection with the employer's trade or
business
* (4) the vehicle was being / not being operated in the ordinary course of
public transport service.
I certify that to the best of my knowledge and belief the above particulars are correct in every respect.