Notice of Accident

(See Regulation 65)

Notice
To

Shri ………………………
Address ………………….

I………………..……….. (Name), S/o …………………… R/o ……….…………………. working in factory as …………………………. since the year …………….. in the Dept.…………………. lost my …………………………………. (Amputation be explained) at ………………………. place …………… time ……………… date, while on duty. My Insurance No. is ………………………
The following person are witnesses to the said accident.

1. Shri ……………………
S/o …………………….
r/o …………………….

2. Shri ……………………
S/o …………………….
r/o …………………….
Working as …………………….
For which pleas take this legal notice.

Signature
*