FORM 18 Prescribed under Rule 123 (3) Report of accident including dangerous occurrence resulting in death or bodily injury ESIC Employer's Code No.............Registration No....... Name & Address of Local ESIC Licence Number.......... Office........... NIC Code Number............ (As given in the licence) 1. Name and address of factory : 2. Name, address and telephone number of the occupier : 3. Nature of Industry (As given in the licence) : 4. Date, shift and hour of accident or dangerous occurrence : 5. Department/Section and exact place where the accident or dangerous occurrence took place : 6. (a)Describe briefly how the accident or dangerous occurrence took place : (b) Did it involve Explosion Fire : Emission of toxic substance(s) Substance(s) emitted 7. Give the total number of persons injured/killed Number of persons injured Number of persons killed
