EMPLOYEES COMPENSATION ORDINANCE FROM

Signature : Name (in block letters) : Position : Date : Sole proprietor Manager

(for and on behalf of the employer)

Partner Officer Chop of Company

A.

Particulars of the employee

Identity Card/Passport No. Address Occupation Male Female An apprentice Yes No

Name of employee (Surname first) Telephone No. Date of Birth / / Day/Month/Year Fax No. Sex

B.

Particulars of employer
Business Registration Certificate No. (Note 2) Trade

Name of employing company/person

Telephone No. Fax No.

Address

C.

Particulars of principal contractor/holding company

Business Registration Certificate No.

Name of principal contractor/holding company

Telephone No. Fax No.

Address

Trade

D.

Description of accident

Describe how the accident happened and state what the employee was doing at the time

State whether the accident Date of accident occurred in the course of work / / Yes No Day/Month/Year Address of the place of accident

Time of accident a.m./p.m.

Result of accident Death Injury

Name of hospital/clinic where the employee received treatment

E.

Details of insurance
Policy No.

Name and address of insurance company at the time of accident (Please refer to the insurance policy)

F.

Details of earnings of the employee

Rest day is 30 (a) (b) not paid not fixed paid fixed on (Day of week) (Note 6)

Average number of working days per month 22 Others (please specify) 24 26

Details of earnings per month for the month immediately preceding the date of accident:

(a) (b) (c)

Basic salary/wages Food allowances/value of free food provided by employer Other items : (please specify) Total (a) + (b) + (c)

KD KD KD

/ month / month / month

KD

/ month

Average monthly earnings of the employee for the past 12 months (or total period of employment, if less than 12 months) preceding the accident were KD / month

G.

Fatal accident (to be completed where accident results in death)

Name and address of next-of-kin of the deceased employee Relationship with the deceased employee

Whether police was notified Yes

(name of police station)

No

Telephone No.

H.

Direct settlement (to be completed only where the injury results in temporary incapacity for not more than 7 days and no permanent incapacity, and the employer and employee have chosen to directly settle the employees compensation claim)
Amount of compensation: KD from / / Day / Month / Year / / Day / Month / Year to / / Day / Month / Year / / Day / Month / Year paid to be paid on Day / / Month / / Year

Period of sick leave

to

Total number of sick leave days :

days

I.

Place of accident (tick one box)

The accident occurred in ---------------Construction site 01 02 03 Building worksite Civil worksite Renovation/repair of existing buildings Shipyard 04 05 06 Floating vessel Non-floating vessel Maintenance workshop Manufactory 07 08 09 10 Activity carried out on the site at the time of accident Production area Maintenance workshop Loading/unloading area Storage area Others 11 12 Container yard Catering establishment Please specify

13

J.

Nature of injury

Describe the nature of injury

Indicate nature of injury (tick one box) 01 02 03 04 05 Abrasion Amputation Asphyxia Burn (heat) Burn 06 07 08 09 10 Contusion & bruise Concussion Laceration and cut Dislocation Crushing 11 12 13 14 15 Electric shock Fracture Puncture wound Sprain & strain Freezing 16 17 18 19 20 Poisoning Irritation Nausea Multiple injuries Others (please specify)

Part of body injured (tick one box) Head Neck & Trunk 21 22 23 24 25 26 Skull/scalp Eye Ear Mouth/tooth Nose Face 31 32 33 34 35 36 Neck Back Chest Abdomen Trunk Pelvis/groin

Upper Limbs 41 42 43 44 45 46 Finger Hand/palm Forearm Elbow Upper arm Shoulder

Lower Limbs 51 52 53 54 55 56 Hip Thigh Knee Leg Ankle Foot 61 Multiple locations (please specify)

K.

Type of accident (tick one box)

01 02 03 04 Trapped in or between objects Injured whilst lifting or carrying Slip, trip or fall on same level Fall of person from height* metres 05 Striking against fixed or stationary object Striking against moving object Stepping on object Exposure to or contact with harmful substance Contact with electricity or electric discharge 10 Trapped by collapsing or overturning object Struck by moving or falling object Struck by moving vehicle Contact with moving machinery or object being machined Drowning 15 Exposure to fire 16 Exposure to explosion 17 Others (Please specify)

06 07 08

11 12 13

09
* distance through which person fell

14

L.

Agents involved, if any (tick one or more boxes)

01 02 03 Equipment for lifting/ conveying Portable power or hand tools Other machinery, please specify: Type : Part causing injury: (a) (b) (c) prime mover transmission part working part 04 Material/product being handled or stored Ladder or working at height Sewage, manhole or other confined space 07 Movable container or package of any kind Floor, ground, stairs or any working surface Gas, vapour, dust or fume 10 Electricity supply, wiring apparatus or equipment 11 Vehicle or associated equipment or machinery 12 Others (Please specify)

05 06

08

09

Describe briefly the agents you have indicated

M.

Sketch (to supplement the descriptions given above, if considered necessary)

For official use only

I.A./Non-I.A.

Investigation

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