HCC MANAGEMENT SYSTEM

PARTICULARS OF COST OF ACCIDENTS

PROJECT: TPSP Period: Mar-20

Other
Any other
Amount of Whether Incidental
Whether expenses
Medical medical Amount Whether expenses like
Type of Amount BOCW Act No. of which is not
No. of days expenses expenses Compensation realised salary paid, taking care of
Incident realised compensatio days covered
Sr. Date of Name of the Injured of incurred on has been paid to victim from if so what is relatives,
(Fatal / from n claimed absent under
No. Incident person hospitalisatio hospitalisatio put up for under BOCW Insuranc the amount police
LTI/RWMC/FIR Insurance from from A,B,C,D
n n (Rs.) insurance Act e (Rs) formalities etc -
ST AID) (Rs) Insurance duty (Rs)
claim (Rs) (Rs) amount
(Y/N)
(A) (Y/N) (C) involved (Rs)
(E)
(B) (D)

Signature with date

PD I/c Signature with date
Project Manager

Format No: HCC F 001 15 058, Rev. 00, Rev. Date: 02.11.2011 Page 1 of 2
 Total
(A+B+C
+D+E)

(Rs)

Signature with date

Project Manager

Format No: HCC F 001 15 058, Rev. 00, Rev. Date: 02.11.2011 Page 2 of 2