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EMPLOYEES' COMPENSATION REGULATIONS - SCHEDULE
SCHEDULE
[regulation 7]
EMPLOYEES' COMPENSATION ORDINANCE
(Chapter 282)
NOTICE OF ACCIDENT BY OR ON BEHALF OF EMPLOYEE
To: (1) ............................................
............................................
............................................
Notice is hereby given that (2) ..........................................................................................
.............................................................................................................................................
on the (3) ......................... day of ...................... 19 ......... at (4) ................................................
..................... met with an accident causing his (5) ....................................................................
and that the cause of the injury/death was (6) ............................................................................
.............................................................................................................................................
And notice is hereby further given that in consequence thereof compensation is claimed from you.
Dated this .......... day of ................. 19 .......
(7) ........................................................
........................................................
........................................................
______________________________________________________________________
(1) Name and address of the employer or principal contractor.
(2) Full name and address of the employee.
(3) Date of accident.
(4) Place of the accident.
(5) Whether disablement or death.
(6) State in plain and ordinary terms the cause or the injury or death.
(7) Signature and address of person giving the notice.
______________
EMPLOYEE'S COMPENSATION ORDINANCE
(Chapter 282)
NOTICE BY OR ON BEHALF OF EMPLOYEE OF INCAPACITY
OR DEATH DUE TO OCCUPATIONAL DISEASE
To: (1) ............................................
............................................
............................................
Notice is hereby given that (2) ..........................................................................................
.............................................................................................................................................
on the (3) ...................... day of ........................... 19 ......... was found to be suffering from the following occupational disease ................................................................................................
.............................................................. believed to be due to his employment by you upon the following work (4) ...................................................................................................................
resulting in the death/partial/total incapacity of a permanent/temporary nature (5) of the employee.
And notice is hereby further given that in consequence thereof compensation is claimed from you.
Dated this ................... day of ..................... 19 .....
(6) ...............................................
______________________________________________________________________
(1) Name and address of the employer or principal contractor.
(2) Full name and address of the employee.
(3) Date upon which disease is said to have been discovered.
(4) State nature of the work which is said to have caused the occupational disease.
(5) Delete whichever is inapplicable.
(6) Signature, name and address of person giving the notice.
___________
EMPLOYEES' COMPENSATION ORDINANCE
(CAP 282)
SECTION 15
NOTICE BY EMPLOYER OF THE DEATH OF AN EMPLOYEE
OR OF AN ACCIDENT TO AN EMPLOYEE RESULTING
IN DEATH OR INCAPACITY
Important Notes
(1) To be completed and returned in DUPLICATE to the Commissioner for Labour-
(a) WITHIN 7 DAYS of the accident in the case of death; or
(b) WITHIN 14 DAYS of the accident in the case of injury; or
(c) WITHIN such period of time as required by the Commissioner for Labour.
(2) An employer who fails to give notice as required or who gives any false or misleading information to the Commissioner for Labour may be prosecuted.
(3) Part I must be completed for each employee. Part II is to be completed only if the accident occurred on a construction site.
(4) If more than one employee was injured or died as a result of an accident, please complete a separate form in duplicate for each employee.
(5) Please "P" in the appropriate box.
(6) Please read the instructions carefully before completing this Form.
____________
FORM 2
EMPLOYEES' COMPENSATION ORDINANCE
(CAP 282)
SECTION 15
NOTICE BY EMPLOYER OF THE DEATH OF AN EMPLOYEE
OR OF AN ACCIDENT TO AN EMPLOYEE RESULTING
IN DEATH OR INCAPACITY
To the Commissioner for Labour
I declare that the information given in this form is, to the best of my knowledge, true and accurate.
Signature: ________________________________________ (for and on behalf of the employer)
Name (in block letters): ._____________________________________
Position: □ Sole proprietor □ Partner
Date: ______________________________ ______________________________
|
-Part I-
A. Particulars of the employee
| Name of employee (Surname first) |
 |
Identity Card/Passport No. |
| Telephone No. |
Fax No. |
Address |
|
Date of birth
_____/_____/____
Day/Month/Year |
Sex
□ Male □ Female |
Occupation |
An apprentice
□ Yes □ No |
B. Particulars of employer
| Name of employing company/person |
Business Registration Certificate No. (Note 2) |
| Telephone No. |
Address |
Trade |
| Fax No. |
|
|
C. Particulars of principal contractor/holding company (Note 3)
| Name of principal contractor/holding company |
Business Registration Certificate No. |
| Telephone No. |
Address |
Trade |
| Fax No. |
|
|
D. Description of accident
Describe how the accident happened and state what the employee was doing at the time (Note 4)
|
State whether the accident occurred in the course of work
□ Yes □ No |
Date of accident
_____/_____/____
Day/Month/Year |
Time of accident
___________ a.m./p.m. |
Result of accident
□ Death □ Injury |
| Address of the place of accident |
|
Name of hospital/clinic where the employee received treatment |
E. Details of insurance (Note 5)
Name and address of insurance company at the time of accident (Please refer to the insurance policy)
|
Policy No. |
F. Details of earnings of the employee
Average number of working days per month
□ 22 □ 24 □ 26 □ 30
□ Others ________________
|
Rest day is
(a) □ not paid □ paid
(b) □ not fixed □ fixed on _____________________
|
| Details of earnings per month for the month immediately preceding the date of accident: (Note 6) |
(a) Basic salary/wages
(b) Food allowances/value of free food provided by employer
(c) Other items: ____________________________________
|
$ ______________/month
$ ______________/month
$ ______________/month
$ ______________/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
|
G. Fatal accident (to be completed where accident results in death)
Whether police was notified
□ Yes _____________________
|
Name and address of next-of-kin of the deceased employee |
Relationship with the deceased employee |
| □ 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)
Period of sick leave
from ______/______/____ to______/______/____
Day/Month/Year Day/Month/Year
_____/_____/____ to_____/_____/____
Day/Month/Year Day/Month/Year
Total number of sick leave days: ____________ days |
Amount of compensation:
$ __________________
□ paid
□ to be paid on ______/______/_____
|
I. Place of accident (tick one box)
The accident occurred in-(Note 7)
Construction site
□ 01 Building worksite
□ 02 Civil worksite
□ 03 Renovation/repair of existing buildings |
Shipyard
□ 04 Floating vessel
□ 05 Non-floating vessel
□ 06 Maintenance workshop |
Manufactory
□ 07 Production area
□ 08 Maintenance workshop
□ 09 Loading/unloading area
□ 10 Storage area |
Others
□ 11 Container yard
□ 12 Catering establishment
□ 13 Please specify
|
Activity carried out on the site at the time of accident (Note 8)
|
|
J. Nature of injury (Note 9)
| Describe the nature of injury |
|
|
|
|
| Indicate nature of injury (tick one box)- |
|
|
|
|
□ 01 Abrasion
□ 02 Amputation
□ 03 Asphyxia
□ 04 Burn (heat)
□ 05 Burn |
□ 06 Contusion & bruise
□ 07 Concussion
□ 08 Laceration and cut
□ 09 Dislocation
□ 10 Crushing
|
□ 11 Electric shock
□ 12 Fracture
□ 13 Puncture wound
□ 14 Sprain & strain
□ 15 Freezing |
□ 16 Poisoning
□ 17 Irritation
□ 18 Nausea
□ 19 Multiple injuries
□ 20 Others
(please specify)
_________________
|
| Part of body injured (tick one box)- |
|
|
|
|
Head
□ 21 Skull/scalp
□ 22 Eye
□ 23 Ear
□ 24 Mouth/tooth
□ 25 Nose
□ 26 Face |
Neck & Trunk
□ 31 Neck
□ 32 Back
□ 33 Chest
□ 34 Abdomen
□ 35 Trunk
□ 36 Pelvis/groin |
Upper Limbs
□ 41 Finger
□ 42 Hand/palm
□ 43 Forearm
□ 44 Elbow
□ 45 Upper arm
□ 46 Shoulder |
Lower Limbs
□ 51 Hip
□ 52 Thigh
□ 53 Knee
□ 54 Leg
□ 55 Ankle
□ 56 Foot |
□ 61 Multiple locations
(please specify)
_____________ |
K. Type of accident (tick one box) (Note 9)
□ 01 Trapped in or between objects
□ 02 Injured whilst lifting or carrying
□ 03 Slip, trip or fall on same level
□ 04 Fall of person from height* ___ metres
* distance through which fell |
□ 05 Striking against fixed or stationary object
□ 06 Striking against moving object
□ 07 Stepping on object
□ 08 Exposure to or contact with harmful substance
□ 09 Contact with electricity or electric discharge |
□ 10 Trapped by collapsing or overturning object
□ 11 Struck by moving or falling object
□ 12 Struck by moving vehicle
□ 13 Contact with moving machinery or object being machined
□ 14 Drowning |
□ 15 Exposure to fire
□ 16 Exposure to explosion
□ 17 Others
(please specify)
_______________
|
L. Agents involved, if any (tick one or more boxes) (Note 9)
□ 01 Equipment for lifting/conveying
□ 02 Portable power or hand tools
□ 03 Other machinery, please specify:
Type: ___________.
Part causing injury:
□ (a) prime mover
□ (b) transmission part
□ (c) working part
|
□ 04 Material/product being handled or stored
□ 05 Ladder or working at height
□ 06 Sewage, manhole or other confined space |
□ 07 Movable container or package of any kind
□ 08 Floor, ground, stairs or any working surface
□ 09 Gas, vapour, dust or fume |
□ 10 Electricity supply, wiring apparatus or equipment
□ 11 Vehicle or associated equipment or machinery
□ 12 Others
|
Describe briefly the agents you have indicated (Note 9)
|
|
M. Sketch (to supplement the descriptions given above, if considered necessary)
|
For official use only |
|
|
|
I.A./Non-I.A. |
|
|
|
|
|
|
|
Investigation |
|
|
|
|
|
|
|
Processed by |
|
|
|
|
|
|
End of Part I
-Part II-
(To be completed if the accident occurred on a construction site)
N. Type of work performed by the employee at the time of accident (tick one box)
□ 01 Concreting
□ 02 Woodworking
□ 03 Glazier work
□ 04 Reinforcement bar bending
□ 05 Bamboo scaffolding
□ 06 Tubular scaffolding |
□ 07 Painting
□ 08 Plastering
□ 09 Arc/gas welding
□ 10 Formwork erection
□ 11 Brick laying
□ 12 Caisson work |
□ 13 Trench work
□ 14 Gas pipe fitting
□ 15 Water pipe fitting
□ 16 Electrical wiring
□ 17 Material handling
□ 18 Lift installation |
□ 19 Slope work
□ 20 Others
(please specify)
____________
|
| Whereabouts on the site such work was performed |
|
O. Machinery involved, if any (tick one or more boxes) (Note 10)
□ 01 Skip/material hoist
□ 02 Passenger hoist/builders' lift
□ 03 Tower crane
□ 04 Mobile crane
□ 05 Lorry-mounted crane |
□ 06 Hydraulic crane
□ 07 Suspended working platform
□ 08 Boatswain's chair
□ 09 Pile driver
□ 10 Boring jig |
□ 11 Bar bender
□ 12 Concrete mixer
□ 13 Air compressor/receiver
□ 14 Others (please specify) |
P. Transporting or construction machinery involved, if any (tick one box)
□ 01 Dump truck
□ 02 Loader
□ 03 Excavator |
□ 04 Bulldozer
□ 05 Grader
□ 06 Compacting roller |
□ 07 Others (please specify)
|
-End of Part II-
Explanatory Notes
Note 1: The signature and company chop which appear in both copies of Form 2 submitted to the Commissioner for Labour should be in the original.
Note 2: If the Business Registration Certificate No. is not available, the Identity Card No. of the employing person should be entered.
Note 3: Section C on particulars of principal contractor/holding company should be completed only when the employer is either-
(a) a subcontractor; or
(b) a subsidiary of a holding company within the meaning of the Companies Ordinance (Cap 32) and which is covered by and specified in the insurance policy taken out by the group of companies to which it belongs.
Note 4: Describe how the accident happened, state what the employee was doing at the time and give details of how the accident happened, e.g. what work was the injured doing, what factors (directly and indirectly) leading to the accident, and how he was injured, etc.
Note 5: The name and address of the insurer as appeared on the insurance policy, instead of those of the broker or agent, should be entered here.
Note 6: Earnings include-
(a) cash wages;
(b) the value of any privilege or benefit which can be estimated in cash, e.g. food, fuel or quarters supplied to the employee if, as a result of the accident, he is deprived of any of them;
(c) overtime or other special remuneration for work done, whether in the form of bonus, allowance or otherwise, if it is of a constant nature; and
(d) customary tips.
But remuneration for intermittent overtime, casual payments of a non-recurrent nature, the value of travelling allowances or concession and the employer's contributions to provident funds are not included.
Note 7: Construction Site
Building worksite: site for building substructure, superstructure, etc. Civil worksite: site for building roads, bridges, etc. Renovation/repair of existing buildings: internal or external renovation, repairing, painting, or external wall cleaning, etc. (Note: Fitting-out in new buildings should be regarded as a building worksite.).
Shipyard
Floating vessel: ship building or repairing conducted on floating shipyard or floating vessel. Non-floating vessel: ship building or repairing conducted on slipway or shore. Maintenance workshop: maintenance workshop of the shipyard where parts of ships are machined, repaired or maintained.
Manufactory
Production area: production workshop or any location where actual production is being carried out.
Maintenance workshop: maintenance workshop of the manufactory where machinery parts are machined, repaired or maintained.
Loading/unloading area: location inside the manufactory assigned for loading and unloading activities including cargo handling. Storage area: location inside the manufactory used for storage purpose.
Others
Container yard: the location where container handling, stacking and maintenance work, etc. are being carried out.
Note 8: Please briefly describe the main function of the workplace at the time of the accident.
Note 9: Please give details on the injury sustained, e.g. while working on a working platform, an employee twisted his ankle and fell 3 m onto the ground.
- In the above example, the following boxes in sections J, K and L should be marked-
- In section J Nature of injury: Sprain & strain (box 14).
- In section J Part of body injured: Ankle (box 55).
- In section K Type of accident: Fall of person from 3 m (box 04).
- In section L Agents involved: Ladder or working at height (box 05).
- In the description of the agents indicated: A platform constructed of a plank which measured 5 m long by 2 m wide and by 5 mm thick.
Note 10: If none of the machinery provided is suitable, please tick box 14 and specify the name of the machinery or briefly describe the type of machinery involved.
(L.N. 469 of 1996)
EMPLOYEES' COMPENSATION ORDINANCE
(CAP 282)
SECTION 15
NOTICE BY EMPLOYER OF THE DEATH OR INCAPACITY OF
AN EMPLOYEE DUE TO OCCUPATIONAL DISEASE
Important Notes
(1) To be completed and returned in DUPLICATE to the Commissioner for Labour-
(a) WITHIN 7 DAYS of the death of the employee; or
(b) WITHIN 14 DAYS of the employee's incapacity; or
(c) WITHIN such period of time as required by the Commissioner for Labour.
(2) An employer who fails to give notice as required or who gives any false or misleading information to the Commissioner for Labour may be prosecuted.
(3) Please "P" in the appropriate box.
(4) Please read the instructions carefully before completing this Form.
_______________
FORM 2A
EMPLOYEES' COMPENSATION ORDINANCE
(CAP 282)
SECTION 15
NOTICE BY EMPLOYER OF THE DEATH OR INCAPACITY OF
AN EMPLOYEE DUE TO OCCUPATIONAL DISEASE
To the Commissioner for Labour
I declare that the information given in this form is, to the best of my knowledge, true and accurate.
Signature: _____________________________________ (for and on behalf of the employer)
Name (in block letters): .__________________________________
Position: □ Sole proprietor □ Partner
Date: _____________________ _______________________________
|
A. Particulars of the employee
| Name of employee (Surname first) |
Identity Card/Passport No. |
| Telephone No. |
Fax No. |
Address |
|
Date of birth
_____/_____/____
Day/Month/Year |
Sex
□Male □Female |
Occupation |
|
An apprentice
□ Yes □ No |
Duration of employment From ________________ to _________________ |
B. Particulars of employer
| Name of employing company/person |
Business Registration Certificate No. (Note 2) |
| Telephone No. |
Address |
Trade |
| Fax No. |
|
|
C. Particulars of principal contractor/holding company (Note 3)
| Name of principal contractor/holding company |
Business Registration Certificate No. |
| Telephone No. |
Address |
Trade |
| Fax No. |
|
|
D. Particulars of the occupational disease
| Name of hospital or clinic where the employee received treatment |
| Date of commencement of the occupational disease _____/_____/_____
|
Disease suffering from |
| Type of work attributed to the occupational disease |
The disease resulted in
□ temporary incapacity □ permanent incapacity □ death
|
E. Details of insurance (Note 4)
Name and address of insurance company at the time of the employee's incapacity or death
(Please refer to the insurance policy)
|
Policy No. |
F. Details of earnings of the employee
Average number of working days per month
□ 22 □ 24 □ 26 □ 30
□ Others ________________
|
Rest day is
(a) □ not paid □ paid
(b) □ not fixed □ fixed on _____________________
|
| Details of earnings per month for the month immediately preceding the date of the employee's incapacity or death: (Note 5) |
(a) Basic salary/wages
(b) Food allowances/value of free food provided by employer
(c) Other items: ____________________________________
|
$ ______________/month
$ ______________/month
$ ______________/month
$ ______________/month |
Average monthly earnings of the employee for the past 12 months (or total period of employment, if less than 12 months) preceding the employee's incapacity or death were
|
G. Fatal case (to be completed where the occupational disease results in death)
Whether police was notified
□ Yes _____________________
|
Name and address of next-of-kin of the deceased employee |
Relationship with the deceased employee |
| □ No |
|
Telephone No. |
H. Direct settlement (to be completed only where the occupational disease 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)
Period of sick leave
from ______/______/____ to _______/______/____
Day/Month/Year Day/Month/Year
_____/_____/____ to _____/_____/____
Day/Month/Year Day/Month/Year
Total number of sick leave days: ____________ days |
Amount of compensation:
$ __________________
□ paid
□ to be paid on ______/______/_____
|
Explanatory Notes
Note 1: The signature and company chop which appear in both copies of Form 2A submitted to the Commissioner for Labour should be in the original.
Note 2: If the Business Registration Certificate No. is not available, the Identity Card No. of the employing person should be entered.
Note 3: Section C on particulars of principal contractor/holding company should be completed only when the employer is either-
(a) a subcontractor; or
(b) a subsidiary of a holding company within the meaning of the Companies Ordinance (Cap 32) and which is covered by and specified in the insurance policy taken out by the group of companies to which it belongs.
Note 4: The name and address of the insurer as appeared on the insurance policy, instead of those of the broker or agent, should be entered here.
Note 5: Earnings include-
(a) cash wages;
(b) the value of any privilege or benefit which can be estimated in cash, e.g. food, fuel or quarters supplied to the employee if, as a result of the accident, he is deprived of any of them;
(c) overtime or other special remuneration for work done, whether in the form of bonus, allowance or otherwise, if it is of a constant nature; and
(d) customary tips.
But remuneration for intermittent overtime, casual payments of a non-recurrent nature, the value of travelling allowances or concession and the employer's contributions to provident funds are not included.
(L.N. 469 of 1996)
______________
EMPLOYEES' COMPENSATION ORDINANCE
(Chapter 282)
DETAILS OF CERTIFICATE AS TO THE AMOUNT OF
COMPENSATION PAYABLE BY THE EMPLOYER
(This form must be completed and lodged with the Registrar
of the Court by the party who desires the certificate to be
made an order of the Court)
1. Name, address and business of employer ......................................................................
...................................................................................................................................
...................................................................................................................................
2. (a) Name and address of employee ..............................................................................
...................................................................................................................................
(b) Occupation(1) ........................................................................................................
(c) Age ................................................. (d) Sex ......................................................
(e) Compensation already received in respect of this accident (if any).............................
...................................................................................................................................
3. (a) Date of accident ....................................................................................................
(b) Cause of accident ..................................................................................................
...................................................................................................................................
(c) Nature and circumstances of injury (2) .....................................................................
...................................................................................................................................
...................................................................................................................................
4. Contract of employment (3) ...........................................................................................
...................................................................................................................................
5. Date of certificate .......................................................................................................
...................................................................................................................................
6. Amount of compensation determined by the Commissioner for Labour (4).........................
...................................................................................................................................
...................................................................................................................................
(a) Amount payable in a lump sum ...............................................................................
(b) Amount and period of periodical payments ..............................................................
...................................................................................................................................
(c) To whom payable ..................................................................................................
7. Date of the Commissioner for Labour's issue of certificate as to compensation ................
...................................................................................................................................
...................................................................................................................................
8. Any other information ..................................................................................................
...................................................................................................................................
...................................................................................................................................
I, .................................... do solemnly and sincerely declare that the foregoing particulars stated are true and I make this solemn declaration conscientiously believing the same to be true and by virtue of the provisions of the Oaths and Declarations Ordinance (Cap 11).
................................................
Signature of applicant.
Declared at ................................................... in Hong Kong this ......................... day of .................................... 19 .......
Before me,
.............................................
Notary Public,
or Commissioner for Oaths.
-----------------------------------------------------------------------------------------------------------------
(1) Full details of the nature of the work and duties on which the employee was employed at the date of the accident.
(2) Give full details and state whether incapacity is total or partial, permanent or temporary. If partial, the degree, and, if temporary, the period of actual or estimated incapacity must be given.
(3) The monthly earnings must be stated, specifying the value of food, fuel or quarters if the employee has been deprived thereof as a result of the accident. (See sections 3 and 11 of the Ordinance.)
(4) Copy of certificate as determined by the Commissioner for Labour must be attached.
(L.N. 383 of 1995; 36 of 1996 s. 30; 47 of 1997 s. 10)
(Schedule replaced L.N. 208 of 1983)
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