[regulation 3]

FORM 1A
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.

[regulation 4]

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
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 “” 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

-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   (please specify)	Rest day is (a) not paid paid (b) not fixed fixed on ________________ (Day of week)
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:   (please specify) Total (a) + (b) + (c)	$_________/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 $_________/month

G. Fatal accident (to be completed where accident results in death)

Whether police was notified Yes   (name of police station)	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 ______/______/____ Day/Month/Year to ______/______/____ Day/Month/Year         ______/______/____ Day/Month/Year to ______/______/____ Day/Month/Year Total number of sick leave days: ____________ days

Amount of compensation: $_____________ paid to be paid on ______/______/____ Day/Month/Year

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 (please specify) _______________
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.

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)
[regulation 4]

FORM 2A
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 “” 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

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 ______/______/____ Day/Month/Year	Disease suffering from
Type of work attributed to the occupational disease	The disease resulted in temporary incapacity permanent incapacity death on ______/______/____ Day/Month/Year

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   (please specify)	Rest day is (a) not paid paid (b) not fixed fixed on _________ (Day of week)
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   (please specify) Total (a) + (b) + (c)	$ __________/month $ __________/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 of police station)	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 ______/______/____ Day/Month/Year to ______/______/____ Day/Month/Year         ______/______/____ Day/Month/Year to ______/______/____ Day/Month/Year Total number of sick leave days: ____________ days

Amount of compensation: $_____________ paid to be paid on ______/______/____ Day/Month/Year

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)

[regulation 5]

FORM 3
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)