Serial No.

(1)
(2)
Date & time of notice

Name & serial number of

the persons involved in the

(3)
register of adult/child
register

ESIC insurance number

(4)
Date

(5)
Time
(6)
(7) Place
[FORM 26]

Cause of accident/major
(8)

accident/dangerous
occurrence
Prescribed under Rule 131

Nature of injury/dangerous
(9)

occurrence

What exactly was the

injured person, if any, doing
(10)

at that time
Injury/dangerous occurrence

Name of person giving the

(11)
Register of accident, major accidents and dangerous occurrences

notice

Name, address and

occupation of two witnesses
(12)

Date of return of injured

person to work
(13)