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WORK INJURY BENEFIT CLAIM FORM by oqp13905

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									                    WORK INJURY BENEFIT CLAIM FORM
Important information – please read carefully
•    This report is to be completed by the employer in case of injury to or death of a workman and returned
     back along with the following documents:
                  - Duly completed DOSH I & II forms
                  - Duly completed WIBA 4 form
                  - Witnesses’ statement (if any), Supervisor’s statement and Claimant’s statement
                  - I.D. copy of the claimant
                  - Any other supporting documents
•    If any detail of information is not available immediately, please do not delay dispatch of this report.
     Such particulars should be sent later.
•    Subject to the provisions of the WIBA an employer is required to report an accident to the Director
     of Occupational Health and Safety either verbally or in writing within 24 hours in case of fatal
     injuries, and within seven days for non-injuries. This includes any accident reported by an
     employee to an employer and the employer alleges that the same arose out of and in the course of
     employment irrespective of the opinion of the employer.
•    Ensure that all the sections of this claim form are fully completed.
•    Please note that this claim form must be completed in English.

•    The ‘Golden Rule’ to follow in the event of an occurrence which may give rise to a claim is :
     NOTIFY US IMMEDIATELY AND ACT AS IF YOU ARE UNINSURED AND ON THIS
     BASIS MINIMISE THE LOSS – DO NOT ADMIT LIABILITY


1.   The Employer
     a)   Name______________________________________________________________________
     b)   Address____________________________________________________________________
     c)   Industry or business___________________________________________________________
     d)   Policy No.____________Commencement date______________Expiry__________________
     e)   Are you registered with the director of occupational health and safety  Yes  No
          If yes, what is your Registration No.______________________________________________

2    The workman involved in employment injury
     a) Full name___________________________________________________________________
     b) Physical address______________________________________________________________
     ________________________________________________________________________
     c) Permanent address_____________________________________________________
     ________________________________________________________________________
     d) Sex        Male     Female
     e)  I.D. No.____________________________________________________________________
     f) Activity undertaken at time of accident___________________________________________
     g) Workman’s job description_____________________________________________________
     h) Status of employment          Permanent  Temporary  Casual  Under a contract
        If under contract, the name of the contractor_______________________________________
        (Kindly attach a copy of the contract)
     i) Professional qualification______________________________________________________
     j) When did the injured person enter your service_____________________________________
     k) Monthly or daily earnings at the time of the accident_________________________________
     l) Has the workman filed a suit                                  Yes       No
     k) Has the workman filed any suit against you previously         Yes       No
        If yes, give details of suit _______________________________________________________
        ____________________________________________________________________________
     k) Is the injured person still in employment                     Yes       No
        If not, state date he/she ceased employment__________________________________________
     l) Was the injured workman suffering at the time of accident from ill health or bodily defect or infirmity
        of any description                                            Yes       No
        If yes, give details of suit _______________________________________________________
         ____________________________________________________________________________

3.   The accident
          a)                  Date____________________Time__________________Place________________
                              __________
     b)   At what time and from whom did you receive notification about the incident_______________
          ____________________________________________________________________________
     c)   Has the incident been reported to the Director of Occupational Health and Safety  Yes            No
          If yes, date reported______________ how___________________________________________
          (Submit documentary evidence with this form)
     d)   Cause of accident_______________________________________________________________
     e)   Was the workman recorded on duty on the day of the accident              Yes         No
     f)   What duty was the workman assigned at the time of the injury___________________________
     g)    If injury was caused by machine:
             - State of machine and parts causing the injury______________________________________
             - Was it fenced or guarded                                            Yes         No
             - Was the machine being cleaned                                       Yes         No
             - What was the general nature of the work going on__________________________________
             - Was it in motion at the time of injury                              Yes         No
             - Who was responsible for switching it ON/OFF ____________________________________
             - Who switched it on__________________________________________________________
             - His/her address______________________________________________________________
               __________________________________________________________________________
             - His permanent home address if different above____________________________________
               __________________________________________________________________________
             - State exactly what the injured person was doing at the time of injury___________________
               __________________________________________________________________________
     h)   If injury not caused by machine(e.g. fire, free fall, carrying heavy objects, e.t.c) name the cause and
          give a brief description on how the workman got
          injured______________________________________
          ______________________________________________________________________________
     i)   If motor vehicle is involved, indicate its registration number, policy number and name & address of
          the insurance company____________________________________________________________
          ________________________________________________________________________

4.   The injury
     a) Nature of injury:
         Fatal        Grievous       Soft tissue      Medical expenses only
     b) If fatal, give names of all dependants of the deceased workman if known____________________
        ________________________________________________________________________
     c) Have the dependants informed the director of occupational health and safety  Yes  No
           If so, when__________________and how______________________________________________
           Particulars of the injury ( as certified by the hospital) are __________________________________
     d)   Is the complaint an occupational disease                                            Yes     No
          If yes, briefly describe when it was first diagnosed______________________________________
          ______________________________________________________________________________
     e)   Was the claimant medically examined before commencing employment                    Yes     No
     f)    State to what extent the injured person is disabled and whether absolutely prevented from following
           his employment___________________________________________________________________
     g)    State whether the injuries are likely to cause any PERMANENT disablement__________________
           ________________________________________________________________________________
     h)    Name the hospital/dispensary/private clinic where he has been treated following the accident______
           ________________________________________________________________________________
     i)    Whether admitted          Yes         No
               If so,    Date of admission_____________________________
                         Date when first treated_________________________
                         Date of discharge______________________________
     j)    Attendance as out-patient prior to and/or subsequent to hospitalization            Yes     No
           From________________________________ To _______________________________________
           Was there a doctor’s medical report               Yes       No (if yes, please forward copy)
     k) Amount expended on treatment________________________________________________
     l) Who paid for it___________________________________________________________________
     m) Was the injury recorded on an occurrence book / injury register           Yes        No
        (If yes, please attach copy)
     n) Were DOSH I & II formed filled              Yes        No     (If yes, please attach copy)
     o) Has he/she resumed work                     Yes        No     When___________________

5.   OBSERVANCE OF INSTRUCTIONS
     a) Were there standing instructions/notices on how to do the assigned work  Yes  No
        Briefly explain________________________________________________________
     b) Was the workman guilty of any misconduct or disobedience to such instructions or
        other orders or rules                     Yes     No
          If so, please give details_______________________________________________________
     c) Was the injured person under the influence of drugs or drinks at the time of accident
               Yes       No
     d) Was the injured workman was provided with protective clothing/guards at the time of
        accident? E.g. gloves, gum boots, helmets, goggles, overalls etc        Yes    No
        If yes, state the items provided____________________________________________
        and was the workman utilizing the gear at the time of injury            Yes    No
        If not, why ___________________________________________________________
        Date of supply________________ Did the workman sign for the gear  Yes          No
        (If yes please attach a copy of the signed register)
     e) Was the workman found without protective at the time of accident        Yes    No
        If no, give reasons why__________________________________________________
     f) Has his immediate supervisor brought to the attention of the insured workman the
        necessity of wearing protective clothing/guards when the former saw the latter
        without these guards at the time of commencement of his work but before the
        occurrence on the date of accident                                      Yes    No
     g) State through whose negligence this injury occurred____________________________
          ____________________________________________________________________________
         ____________________________________________________________________________
6.   State the names, addresses (permanent and home) of the person(s) who witnessed this accident
     a)_______________________________________________________________________________
     _________________________________________________________________________________
     b)_______________________________________________________________________________
     _________________________________________________________________________________
     c)________________________________________________________________________________
     _________________________________________________________________________________

7.   Brief statement(s) of the above named person(s) who witnessed the accident when it occurred
     a)________________________________________________________________________________
     _________________________________________________________________________________
     _________________________________________________________________________________
     Name________________________________ Designation__________________________________
     Date__________________________________Signature____________________________________

     b)________________________________________________________________________________
     _________________________________________________________________________________
     _________________________________________________________________________________
     Name________________________________ Designation__________________________________
     Date__________________________________Signature____________________________________

     c)________________________________________________________________________________
     _________________________________________________________________________________
     _________________________________________________________________________________
     Name________________________________ Designation__________________________________
     Date__________________________________Signature____________________________________

     (The above are factual to the best of my/our knowledge, information and belief)

     The below part must be completed
                                                               Please stamp here using the signature of the
     Date______________________________________                employer or the company’s authorized stamp

     Name_____________________________________

     Signature of employer________________________

     Designation________________________________


     STATEMENT OF WAGES

     The object of this statement is to ascertain the injured person’s average monthly earning. Please
     therefore observe the following instructions carefully. Failure to do so will entail unnecessary
     correspondence and cause undue delay in the settlement of the claim.
     1.    If the injured person has been in Employer’s service during a continuous period of more
           than one month immediately preceding the accident, the wages that have been paid or fallen
           due for payment, to him in each month of such period (not exceeding 12 preceding months
           in all) must be entered in this statement.
2.    If the injured person has been in employer’s service for less than one month ,there must be
      entered in the statement the wages paid to another workmen employed on the same kind of
      work by the employer during the 12 months preceding the accident.


                                                BONUS VALUE OF FREE QUATRERS & AND
 MONTH           WAGES                          ALLOWANCES




 Total
                 Total including Allowance


a) Were the above stated wages paid, or fallen due to for payment to the injured person?
      Yes        No
     If not, state to whom__________________________________________________________
b) Was the injured person absent from work at any time, during the above stated period,
   for 114 or more consecutive days                 Yes      No
   If so, give the following particulars;
   Absent for________days from____________________to______________________

								
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