The Federated Employers Mutual Assurance Company (RF) (Pty) Ltd (Reg. No. 1936/008971/07)
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1 The Federated Employers Mutual Assurance Company (RF) (Pty) Ltd (Reg /008971/07) Step 1 Complete EMPLOYER S REPORT in full and SUBMIT WITHIN 7 DAYS without delay. Step 2 Sign and date from where indicated. Step 3 Hand Part B to the injured employee before he/she goes for initial medical treatment and instruct him/her to hand Part B to the medical practitioner or hospital concerned. In serious cases Part B must be forwarded to the medical practitioner or hospital without delay. Step 4 Forward completed PART A together with a First Medical Report (if available) to: THAT REGIONAL OFFICE OF THE FEDERATED EMPLOYERS MUTUAL ASSURANCE COMPANY (RF) (PTY) LTD (FEM) WITH WHOM YOU HAVE INSURED YOUR LIABILITY IN TERMS OF THE COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, See Reverse Part B Page 1 for addresses.
2 (COMPULSORY TO COMPLETE) Employer... PART A PAGE 2 Date of accident... Employee... Employee's I.D..... FURTHER PARTICULARS OF EMPLOYEE 46. Earnings of employee at the time of the accident: R / Week R / Fortnight R / Month Basic wage... Commission of a constant nature... Overtime of a constant nature... Allowances of a recurrent nature: a) Bonuses (i.e. 13th cheque)... b) Other (specify nature)... Cash value of: a) Free food... b) Free quarters... Holiday fund Cash Stamp... Other payments (specify nature) In terms of section 47 (3) of the Act, the employer is liable for the payment of compensation (i.e. 75% of the wages) for the first three months from the date of accident or until the employee resumes work (refundable by FEM) a) If you have already paid cash to the employee, state the amount R b) For what period were such payments made?... From.../.../... To.../.../... Number of days per week worked by the employee Date on which the employee ceased work due to the accident.../.../ Time Did the employee complete his shift on the day of the accident? Date on which the employee resumed work.../.../ Time... (If the employee has not yet resumed work, a Resumption Report must be submitted as soon as he/she resumes duty). 54. Next of Kin, family or friends contact details a) Name... b) Address... c) FURTHER PARTICULARS 55. Should the employee, to your knowledge have any physical defect, suffer from any serious disease prior to the accident or previously have received compensation for permanent disablement, give full particulars Was first aid given in this case? If a medical practitioner treated the employee, state the name of the practitioner If the employee received treatment at a hospital, state the name of the hospital Was the accident caused by the employee's: (a) Deliberate non-compliance with directions?. (b) Reckless disregard of the terms of any law or statutory regulation designed to ensure the health and safety of employees and the prevention of accidents?... (c) NB: Action while under the influence of liquor or drugs?... (If any reply is in the affirmative, the employee must furnish an explanatory statement which must then be attached hereto together with your comments thereon). 60. Name, address and contact number of anybody: a) Who witnessed the accident?... b) Who was aware of the accident at the time?. 61. Total number of employees injured in the same accident? If the accident was investigated by the S.A. Police, state the name of the police station and case number If motor vehicles were involved, furnish registration number(s)... SAFETY QUESTIONNAIRE AND ANY ADDITIONAL DETAILS MUST BE SUPPLIED ON PART A PAGE 3
3 EMPLOYER'S REPORT OF ACCIDENT COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993 Section 6(A) - Annexure 13 The Federated Employers Mutual Assurance Company (RF) (Pty) Ltd Instructions: Complete the form in block letters and mark appropriate areas (X) EMPLOYER Claim. Office Date PART A PAGE 1 (For official use only) 1. Name of company registered with THE FEDERATED EMPLOYERS' MUTUAL ASSURANCE COMPANY (RF) (PTY) LTD (FEM) 2. FEM Policy number WCC Reference number - if known 3. Contact person Street address Postal code Postal code Tel.. (...) Fax.. (...) address Situation of business/site Nature of business, trade or industry... EMPLOYEE (CERTIFIED COPY OF IDENTITY DOCUMENT TO BE ATTACHED) 13. a) Is the injured employee a ACCIDENT 32. Date of accident.../.../ Date on which the employee reported the accident.../.../ What task was the employee performing at the time of the accident? b) Is the employee in your direct employ or that of a subcontractor? Surname First names I.D. / Passport Date of birth.../.../ Sex working director working member of a CC owner of partner in the business? t applicable Citizen of... Work permit.... (If not a citizen of South Africa, please attach a copy of the employee's work permit) 20. Personnel / Staff Occupation... Period of experience in task performed (years / months).../ Time of accident Place of accident (Site) District Province Was his/her action at the time of the accident in connection with your trade or business? Short description of how the accident occurred (ALSO give a full description and mark the applicable items on Part A Page 3) (Refer to the machine / process involved and whether the injured employee fell or was struck and all the factors contributing to the accident) 38. Marital State Postal code Period in your employ (years / months).../ Expected period of disablement (days) Directly employed Time reported Subcontractor Male Married Female 23. Street address Postal code Tel.. (...) Fax.. (...) CELL. NO.... Single 0-13 days 14 & more Please complete in detail to ensure early finalisation. 43. Was the accident a traffic accident on a public road? Nature of injury sustained. (e.g. index finger of right hand crushed)... Mark any of the following if applicable... Fatal Amputation Unconsciousness 45. Are you satisfied that the employee was injured in the manner alleged by him (If not, give reasons)?... DECLARATION BY EMPLOYER OR AUTHORISED PERSON I hereby declare that the particulars, shown in items 1 to 67 of this report, of an alledged injury on duty are to the best of my knowledge and belief true and accurate. Name and position... Signed on this... day of... in the year... PART A PAGE 2 MUST ALSO BE COMPLETED, PLEASE. Signature...
4 (COMPULSORY TO COMPLETE) Employer... Employee... PART A PAGE 3 Date of accident... Employee's I.D Continuation of point 42 of the previous page. Contributing factors/causes applicable. (Mark the applicable item/s at A and B) A) Defective Plant Defective machine Unfavorable conditions at work Fault of employer Fault of injured employee Fault of supervisor B) Railway Building work Electricity Chemicals Poisoning Burns Explosions Rotating machine Press/Rollers Woodworking machine Lifting machine Hand tool Other machinery (Specify)... Any other contributing factors, not mentioned above (Specify)... SAFETY QUESTIONNAIRE 64. Did the employee receive induction training? Was the employee wearing the required safety equipment at the time of the accident? Was the employee supplied with safety equipment?... Hard hat Masks Earplugs Harness Goggles Footwear Gloves Other If "Other", specify If this was a motor vehicle accident: a) When was the vehicle last serviced?... b) When were the tyres last changed?... c) Was the vehicle roadworthy?... d) Carrying capacity of the vehicle i) Tare... ii). Persons.... e) Was the employee licensed to drive this type of vehicle?. ADDITIONAL DETAILS OR COMMENTS The rest of this page must be used for any additional details or comments regarding the accident.
5 EMPLOYER'S REPORT OF ACCIDENT PART B PAGE 1 COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993 (For official use only) Section 6(A) - Annexure 13 Claim. The Federated Employers Mutual Assurance Company (RF) (Pty) Ltd Office Instructions: Date Complete the form in block letters and mark appropriate areas (X) EMPLOYER 1. Name of company registered with THE FEDERATED EMPLOYERS MUTUAL ASSURANCE COMPANY (RF) (PTY) LTD (FEM) 2. FEM Policy number WCC Reference number - if known 3. Contact person Street address Postal code Postal code Tel.. (...) Fax.. (...) address Situation of business/site Nature of business, trade or industry... EMPLOYEE (CERTIFIED COPY OF IDENTITY DOCUMENT TO BE ATTACHED) 13. a) Is the injured employee a working director working member of a CC owner of partner in the business? t applicable b) Is the employee in your direct employ or that of a subcontractor?... Directly employed Subcontractor 14. Surname First names I.D. / Passport Date of birth.../.../ Sex Male Female Citizen of... Work permit.... (If not a citizen of South Africa, please attach a copy of the employee's work permit) 20. Personnel / Staff Occupation Marital State Married Single 23. Street address Postal code Postal code Tel.. (...) Fax.. (...) CELL. NO Period in your employ (years / months).../ Expected period of disablement (days) 0-13 days 14 & more ACCIDENT 32. Date of accident.../.../ Time of accident Place of accident (Site) District Province Date on which the employee reported the accident.../.../ Time reported What task was the employee performing at the time of the accident? Period of experience in task performed (years / months).../ Was his/her action at the time of the accident in connection with your trade or business? Short description of how the accident occurred (ALSO give a full description and mark the applicable items on Part A Page 3) (Refer to the machine / process involved and whether the injured employee fell or was struck and all the factors contributing to the accident) 43. Was the accident a traffic accident on a public road? Nature of injury sustained. (e.g. index finger of right hand crushed)... Mark any of the following if applicable... Fatal Amputation Unconsciousness 45. Are you satisfied that the employee was injured in the manner alleged by him (If not, give reasons)?... DECLARATION BY EMPLOYER OR AUTHORISED PERSON I hereby declare that the particulars, shown in items 1 to 67 of this report, of an alledged injury on duty are to the best of my knowledge and belief true and accurate. Name and position... Signature... Signed on this... day of... in the year...
6 PART B PAGE 2 DIRECTIONS TO MEDICAL PRACTITIONER / HOSPITAL te that if liability is not accepted by The Federated Employers Mutual Assurance Company (RF) (Pty) Ltd, medical expenses cannot be paid. The first medical report must be completed in duplicate and care must be taken to ensure that the full names of the employee and employer and the employee's I.D. number as shown on this form, appear thereon. The original must be forwarded to that regional office of The Federated Employers Mutual Assurance Company (RF) (Pty) Ltd with which the employer has insured his Compensation for Occupational Injuries and Diseases Act liability as soon as possible whilst the duplicate must be kept by the medical practitioner or hospital together with this form. REGIONAL OFFICES OF THE FEDERATED EMPLOYERS MUTUAL ASSURANCE COMPANY (RF) (PTY) LTD HEAD OFFICE Private Bag 87109, Houghton, Oxford Rd, Houghton Estate, Johannesburg, 2198 (011) (011) Branch Manager Johannesburg A. Reddy Private Bag 87109, Houghton, Oxford Rd, Houghton Estate, Johannesburg, 2198 (011) (011) Branch Manager Cape Town B. Mangisa P.O. Box 2555, Cape Town, th Floor, 80 Strand Street, Cape Town, 8001 (021) (021) Branch Manager Durban S. Munnoo P.O. Box 1157, Umhlanga Rocks, st Floor RewardCo Building, 2 Ncondo Place, Umhlanga Ridge, 4320 (031) (031) THE DEPARTMENT OF LABOUR CONTACT DETAILS Call Center Fax (012) (012) (012) (012) Website cf-info@labour.gov.za THE COMPENSATION COMMISSIONER COMPENSATION HOUSE CNR. SOUTPANSBERG AND HAMILTON ROAD P.O. BOX 955 PRETORIA 0001
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