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NATIONAL SOCIAL SECURITY WELFARE CORPORATION www. nasscorp.org. lr FORM B26 15th Street Payne Avenue Monrovia nasscorp nasscorp.org. lr ACCIDENT REPORT FROM EMPLOYER This form must be completed and sent to the appropriate office of the Corporation* Within 48 hours of the accident being reported to you if the injured person is likely to suffer permanent disablement or death Within 14 days of the accident being reported to you in other cases Where possible the form should be accompanied by the following a Medical Certificate and Claim Form for whichever benefit is claimed Form providing details of the injured person s earnings except where only a claim for medical expenses is being made It is an offense under the Social Security Act to fail to report an accident to the Corporation within specified time limits PLEASE TYPE OR USE BLOCK LETTERS in answering the following questions PART 1 DETAILS OF EMPLOYER Name of Employer Industry P. O. Box No Address of Employers PART 2 Employer Code No* Telephone No* DETAILS OF INJURED PERSON Full Name Address Department/Shift Working Location Date of Birth Social Security No* Sex M F Occupation Works No* If any Date of Starting Employment Do you agree that this person was your employee at the time of the accident Yes details Please turn over or No If No give further PART 3 DETAILS OF ACCIDENT Date Time Location of Accident 2a Exactly what was the injured person doing at the time of the accident 2b Was this something which he was authorized to do in connection with his job Yes further details 3 If the accident did not happen on your premises please explain why the injured person was there 4a Between what hours was the injured persos supposed to work on the day of accident 4b Between what time did he start work in that day and what time did he finish work 5a Describe briefly how the accident happened 5b Name and address of witnesses 2 if possible 5c When was the accident reported to you 6a Nature and extend of injury e*g* Loss of finger fracture etc* 6b Has the injured person returned to work Yes or No If YES give date 6c If the injured has died give date of birth 6d Name of the physician dispensary or hospital from whom or where the injured person received or Is receiving treatment 7 Are you paying wages to the injured person while he is absent from work Yes I certify that to the best of my knowledge and belief the above particulars are correct in every respect. Temporary Disablement Benefit Wishes to claim Medical Benefit Death Benefit Permanent Disablement Benefit SignatureDate PositionEmployers Stamp. lr ACCIDENT REPORT FROM EMPLOYER This form must be completed and sent to the appropriate office of the Corporation* Within 48 hours of the accident being reported to you if the injured person is likely to suffer permanent disablement or death Within 14 days of the accident being reported to you in other cases Where possible the form should be accompanied by the following a Medical Certificate and Claim Form for whichever benefit is claimed Form providing details of the injured person s earnings except where only a claim for medical expenses is being made It is an offense under the Social Security Act to fail to report an accident to the Corporation within specified time limits PLEASE TYPE OR USE BLOCK LETTERS in answering the following questions PART 1 DETAILS OF EMPLOYER Name of Employer Industry P. O. Box No Address of Employers PART 2 Employer Code No* Telephone No* DETAILS OF INJURED PERSON Full Name Address Department/Shift Working Location Date of Birth Social Security No* Sex M F Occupation Works No* If any Date of Starting Employment Do you agree that this person was your employee at the time of the accident Yes details Please turn over or No If No give further PART 3 DETAILS OF ACCIDENT Date Time Location of Accident 2a Exactly what was the injured person doing at the time of the accident 2b Was this something which he was authorized to do in connection with his job Yes further details 3 If the accident did not happen on your premises please explain why the injured person was there 4a Between what hours was the injured persos supposed to work on the day of accident 4b Between what time did he start work in that day and what time did he finish work 5a Describe briefly how the accident happened 5b Name and address of witnesses 2 if possible 5c When was the accident reported to you 6a Nature and extend of injury e*g* Loss of finger fracture etc* 6b Has the injured person returned to work Yes or No If YES give date 6c If the injured has died give date of birth 6d Name of the physician dispensary or hospital from whom or where the injured person received or Is receiving treatment 7 Are you paying wages to the injured person while he is absent from work Yes I certify that to the best of my knowledge and belief the above particulars are correct in every respect.