FORM 15: ACCIDENT BOOK Regulation 66 Serial No _______________ Date of notice ______________ Time of notice __________________ Name and address of the injured person __________ Sex ____________ Age ____________ Insurance No _______________________ Shift, department and occupation of employee ________________ Injury _______________________ Date _________________________ Time ___________________________ Place ___________________________ Cause of injury ___________________ Nature of injury ___________________ What exactly was the injured person doing at the time of injury ______ Name, occupation, address and signature or the thumb impression of the persons giving notice ___________________ Signature and designation of the person who makes the entry _______ Name, address and occupation of two witnesses __________________________________ ________________________________________________________________________ Remarks, if any ___________________ | 
