This form must be filled by an Employer to claim for an injury of an Employee. This form is only valid if the Employer has a active Employee Insurance Policy from Bajaj Allianz and the Employee is injured while working for the employee.
EMPLOYERS’ LIABILITY CLAIM FORM
Policy no ____________________________________________
Particulars of accident to be furnished by the EmployerThese 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 Claim Form.P.S. – If any details of information are not readily available PLEASE DO NOT DELAY
DESPATCH of this form but send supplementary advices late r.
PART – I: THE EMPLOYER
NAME OF POLICY HOLDER:
BUSINESS:
ADDRESS:
DISTRICT:PART II – THE INJURED PERSON
NAME:
RELIGION OR CASTE:
AGE:
SEX:
LOCAL ADDRESS:
OCUPATION IN WHICH INIURED IS
EMPLOYED:
ON WHAT WORK WAS THE INJURED
P ERSON ENGAGED AT THE TIME OF
ACCIDENT?
WAS THE INJURED ACTUALLY
WORKING AT THE TIME OF ACCIDENT?
IS THE INJURED PERSON IN YOUR
DIRECT EMPLOY?
IF NOT GIVE NAME AND ADDRESS OF
CONTRACTOR AND NATURE OF
CONTRACT:
NAME OF THE HOSPITAL TAKEN TO:
STATE WHETHER STILL IN HOSPITAL OR
DISCHARGED?
STATE NATURE OF INJURY:
DID INJURED PERSON ACTUALLY
CEASE WORK AND IF SO ON WHAT
DATE?
HAS INJURED PERSON RESUMED DUTY
SINCE AND IF SO ON WHAT DATE?
WHAT IS THE PROBABALE PERIOD OF
DISABLEMENT?PART III: THE ACCIDENT
DATE OF ACCIDENT: TIME: PLACE:
DID THE ACCIDENT OCCUR ACTUALLY
WITHIN YOUR WORK PREMISES, IF NOT
WHERE DID IT HAPPEN?
ON WHAT DATE DID YOU RECEIVE
NOTICE OF ACCIDENT AND FROM
WHOM, IF IN WRITING PLEASE ATTACH
TO THIS FORM?
HOW EXACTLY DID THE ACCIDENT
OCCUR?
IF THE ACCIDENT DUE TO MACHINERY
STATE WHETHER FENCED OR NOT:
WAS THE INJURED PERSON UNDER THE
INFUENCE :OF DRINKS OR DRUGS AT
THE TIME OF ACCIDENT?
GIVE NAME OF THE SUPERVISOR:The above replies are true to the best of our knowledge and belief.
Place:____________________
Signature __________________Date:____________________
Name &
Designation:________________
STATEMENT OF INJURED PERSON’S EARNING
Statement of wages fallen due to payment to _______________________________ in the
employ of__________________________________________________________ for 12
months prior to the date of his accident or wages earned during such shorter period as he may
have been in the employer service.
Note: The object of this part of form is to ascertain the extra average monthly earning of the
injured person. It is essential that it should carefully and correctly filled in, if the injured
person has been in service less than twelve months his date d 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 _________________
Date on which the injured person resumed duty after a continuos absence of more than 14
days _______________________________Month and
year
Wages earned
(Including overtime)
Value of bonus, food subsidy, if
any free quarter and any other
allowance etc.
Absences
Rs Rs
1
2
3
4
5
6
7
8
9
10
11
12
Total
earning in
the periodTotal Including all Allowance Rs ___________________
SPECIAL NOTICE
If the workers period of service was less than one month give the} Rs
average monthly wages a workman employed on similar work* Please state the exact nature of the allowance and or bonus.
* In column absences 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 earning etc is to the best of my knowledge and belief accurate.Date: Signature of Employer