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

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

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Country of origin: AUSTRALIA
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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 ‘ü’ in the appropriate box.
(4) Please read the instructions carefully before completing this Form.
L.D. 110(a)(S)(Rev/96)
[reg.4]
- 2 -
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
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 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
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signature
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- 3 -
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 $ / 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 employee’s incapacity or death were
$ / month
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 / / 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 -
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.
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FORM 2A: reg.4 EMPLOYEES COMPENSATION ORDINANCE (CAP. 282) (QBE)

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Completed 10 June 2021

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