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FORM 2: [reg.4] EMPLOYEES COMPENSATION ORDINANCE (CAP. 282) (QBE)

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- 1 -
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 ‘ü’ in the appropriate box.
(6) Please read the instructions carefully before completing this Form.
L.D. 27(a)(S)(Rev.96)
[reg.4]
- 2 -
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
Manager Officer
Date :
Chop of Company (Note 1)
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
ØPart I×
click to sign
signature
click to edit
- 3 -
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 $ / month
(b) Food allowances/value of free food provided by employer $ / month
(c) Other items : $ / month
(please specify)
Total (a) + (b) + (c) $ / 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 / / 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 / /
Day / Month / Year
0.00
- 4 -
I. Place of accident (tick one box)
The accident occurred in (Note 7)
Construction site Shipyard Manufactory Others
01 Building worksite 04 Floating vessel 07 Production area 11 Container yard
02
03
Civil worksite
Renovation/repair
of existing buildings
05
06
Non-floating vessel
Maintenance
workshop
08
09
10
Maintenance
workshop
Loading/unloading
area
Storage area
12
13
Catering
establishment
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 06 Contusion &
bruise
11 Electric shock 16 Poisoning
02 Amputation 07 Concussion 12 Fracture 17 Irritation
03 Asphyxia 08 Laceration and cut 13 Puncture wound 18 Nausea
04 Burn (heat) 09 Dislocation 14 Sprain & strain 19 Multiple injuries
05 Burn 10 Crushing 15 Freezing 20 Others
(please specify)
Part of body injured (tick one box) —
Head Neck & Trunk Upper Limbs Lower Limbs
21 Skull/scalp 31 Neck 41 Finger 51 Hip 61 Multiple locations
22 Eye 32 Back 42 Hand/palm 52 Thigh
(please specify)
23 Ear 33 Chest 43 Forearm 53 Knee
24 Mouth/tooth 34 Abdomen 44 Elbow 54 Leg
25 Nose 35 Trunk 45 Upper arm 55 Ankle
26 Face 36 Pelvis/groin 46 Shoulder 56 Foot
K. Type of accident (tick one box) (Note 9)
01
02
03
04
Trapped in or between
objects
Injured whilst lifting or
carrying
Slip, trip or fall on same
level
Fall of person
from height*
metres
* distance through which
person fell
05
06
07
08
09
Striking against
fixed or
stationary object
Striking against
moving object
Stepping on
object
Exposure to or
contact with
harmful
substance
Contact with
electricity or
electric discharge
10
11
12
13
14
Trapped by
collapsing or
overturning object
Struck by moving
or falling object
Struck by moving
vehicle
Contact with moving
machinery or
object being
machined
Drowning
15
16
17
Exposure to fire
Exposure to
explosion
Others
(Please specify)
- 5 -
L. Agents involved, if any (tick one or more boxes) (Note 9)
01
02
03
Equipment for lifting/
conveying
Portable power or
hand tools
Other machinery,
please specify:
Type :
Part causing injury:
(a) prime mover
(b) transmission
part
(c) working part
04
05
06
Material/product
being handled
or stored
Ladder or working
at height
Sewage, manhole
or other
confined space
07
08
09
Movable container
or package of
any kind
Floor, ground,
stairs or any
working surface
Gas, vapour, dust
or fume
10
11
12
Electricity supply,
wiring apparatus
or equipment
Vehicle or associated
equipment or
machinery
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
Ø
End of Part I
×
- 6 -
Ø
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 07 Painting 13 Trench work 19 Slope work
02 Woodworking 08 Plastering 14 Gas pipe fitting 20 Others
03 Glazier work 09 Arc/gas welding 15 Water pipe fitting
(please specify)
04 Reinforcement bar bending 10 Formwork erection 16 Electrical wiring
05 Bamboo scaffolding 11 Brick laying 17 Material handling
06 Tubular scaffolding 12 Caisson work 18 Lift installation
Whereabouts on the site such work was performed
O. Machinery involved, if any (tick one or more boxes) (Note 10)
01 Skip/material hoist 06 Hydraulic crane 11 Bar bender
02 Passenger hoist/builders’ lift 07 Suspended working platform 12 Concrete mixer
03 Tower crane 08 Boatswain’s chair 13 Air compressor/receiver
04 Mobile crane 09 Pile driver 14 Others (please specify)
05 Lorry-mounted crane 10 Boring jig
P. Transporting or construction machinery involved, if any (tick one box)
01 Dump truck 04 Bulldozer 07 Others (please specify)
02 Loader 05 Grader
03 Excavator 06 Compacting roller
Ø
End of Part II
×
- 7 -
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.
- 8 -
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 —
l
In section J Nature of injury: Sprain & strain (box 14).
l
In section J Part of body injured: Ankle (box 55).
l
In section K Type of accident: Fall of person from 3 m (box 04).
l
In section L Agents involved: Ladder or working at height (box 05).
l
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.
Supplementary Information on Accidents on Construction Sites
Explanatory Notes:
This is not
a statutory form required to be submitted under the Employees’ Compensation Ordinance for
reporting accident. However, the co-operation of employers is sought to complete Sections I, II and III
below for accidents occurred on construction sites. The supplementary information will be used for the
purpose of accident analysis within Government and by the public bodies concerned.
I. Particulars of Worksite
Commencement of Construction Work: _______ / _______
Month / Year
Expected Date of Completion: _______ / _______
Month / Year
Contractor Name:
Site Address:
Contract No. (if available):
Date of Accident:
Contact Telephone:
_______________________________
Chop of Company
II. Particulars of Project
(A) Nature of Project
□ Civil Engineering □ Superstructure □ Maintenance and Repair
(B) Private Project
□ Yes □ No
If Yes, please give name and contact telephone no. of If No, please indicate below the type of
authorized person or project manager public works/government project
Name: _______________________________
Position: _____________________________
Tel. No.: _____________________________
(C) Public Works or Government Project
□ 01 Architectural Services Department
□ 02 Buildings Department
■ 03
□ 04 Drainage Services Department
□ 05 Electrical & Mechanical Services Department
□ 06 Highways Department
■ 07
□ 08 Water Supplies Department
□ 09 Housing Department
■ 10
■ 11
□ 12 Airport Authority Hong Kong
□ 13 Agriculture, Fisheries & Conservation Department
□ 14 Environmental Protection Department
□ 15 Home Affairs Department
■ 16
■ 17
□ 18 Food & Environmental Hygiene Department
□ 19 Civil Engineering & Development Department
□ 20 MTR Corporation Limited
□ 99 Others (please specify)
III. Particulars of Place of Fall (If Injured by Fall from Height)
□ 01 Bamboo scaffold □ 04 Working platform/falsework □ 07 Ladder
□ 02 Fragile structure □ 05 Unfenced edges & lift shaft opening □ 08 Others
□ 03 Material hoistway □ 06 Unfenced/insecurely covered opening
Please ‘
9
’ in the appropriate box.
L.D. 27(C) Rev (12/2007)
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FORM 2: reg.4 EMPLOYEES COMPENSATION ORDINANCE (CAP. 282) (QBE)

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Completed 10 June 2021

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