Download ESIC FORM 12
As per ESIC Regulation 68 Report of accident by an employer
Every employer shall send a report in [Form 12] to the nearest [Branch Office] and to the nearestinsurance medical officer—
(i) immediately if the injury is serious, i.e. it is likely to cause death or permanent disablementor loss of a member; and
(ii) in any other case within 24 hours after the receipt of the notice under regulation 65 or ofthe time when the accident came to the notice of the employer or of a foreman or other official under whose supervision the insured person was employed at the time of the accident or any other person designated for the purpose by the employer :PROVIDED that in case of a serious injury, and particularly when the injury results in death at the place of employment, the report to the Insurance Medical Officer and the [Branch Office] shall be sent through a special messenger, or otherwise, as speedily as may be practicable under the circumstances
PROVIDED FURTHER that where a report of the accident is made by the employer under the Factories Act, 1948, the report to the local office and to the insurance medical officer may be made in the same form as is prescribed under the Factories Act, 1948, provided that all the additional information required under [Form 12] is added thereto:
PROVIDED FURTHER that it shall not be necessary for the employer to send a report in Form
16 if an employment injury is caused by any occupational disease specified in Schedule III to the Workmen’s Compensation Act, 1923; but the employer shall furnish on demand to the appropriate [branch office], within such reasonable period as may be specified, such information and particulars as shall be required of the nature of and other relevant circumstances relating to any employment specified in Schedule III to the Workmen’s Compensation Act, 1923.