Get Form 17 - Labour Department, Puducherry

Filling out the FORM 17 for the Labour Department in Puducherry is essential for reporting workplace accidents. This guide provides clear instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out FORM 17 online.

1. Click the ‘Get Form’ button to obtain the form and open it in your editing program.
2. Begin by entering the name of the occupier or employer, as well as their E.S.I. Employer’s Code Number.
3. Provide the address of the works or premises where the accident occurred and specify the nature of the industry along with the E.S.I. Insurance Number.
4. Indicate the branch or department and the specific location within the premises where the accident took place.
5. Fill in the name and address of the injured person.
6. Provide details about the injured person which includes their sex, age (referring to their last birthday), and occupation.
7. State the local E.S.I. office to which the injured person is affiliated.
8. Record the date and hour of the accident.
9. Note the hour at which the injured person started work on the day of the accident and whether they will receive full wages for that day.
10. Describe the cause or nature of the accident.
11. Provide additional details regarding the cause of the accident.
12. If the accident was caused by machinery, give the name of the machine and the specific part involved.
13. State whether the machine was powered at the time of the accident and describe what the injured person was doing.
14. Assess whether the injured person was acting against any applicable laws or orders and provide details if applicable.
15. If the accident occurred while traveling in the employer’s transport, provide relevant details on the conditions of travel.
16. If applicable, describe any emergency situation related to the accident and detail the injured person's employment status at the time.
17. Summarize how the accident occurred briefly.
18. List names and addresses of any witnesses.
19. Detail the nature and extent of the injury, along with its specific location.
20. If the accident was not fatal, state whether the injured person was disabled for more than 48 hours and provide their date of return to work.
21. Provide information about the physician, dispensary, or hospital where the injured person received treatment, as well as the name of any chosen dispensary or doctor.
22. Indicate if the injured person died and, if so, provide the date of death.
23. Finalize with a certification stating that the particulars provided are correct. Include the signature, name and designation of the occupier or manager, and their address with code number.
24. After filling out the form, save changes, download, print, or share the completed document as required.

Complete and submit your FORM 17 online for an efficient accident reporting process.