WORK INJURY BENEFIT CLAIM FORM Important information please read carefully i. This report is to be completed by the employer in case of injury to or death of a workman and returned back along with the following documents: Duly completed DOSH I & II forms Duly completed WIBA 4 form Witnesses statement (if any), Supervisor s statement and Claimant s statement I.D. copy of the claimant Any other supporting documents ii. If any detail of information is not available immediately, please do not delay dispatch of this report. Such particulars should be sent later. iii. Subject to the provisions of the WIBA an employer is required to report an accident to the Director of Occupational Health and Safety either verbally or in writing within 24 hours in case of fatal injuries, and within seven days for non-injuries. This includes any accident reported by an employee to an employer and the employer alleges that the same arose out of and in the course of employment irrespective of the opinion of the employer. iv. Ensure that all the sections of this claim form are fully completed. v. Please note that this claim form must be completed in English. vi. The Golden Rule to follow in the event of an occurrence which may give rise to a claim is : NOTIFY US IMMEDIATELY AND ACT AS IF YOU ARE UNINSURED AND ON THIS BASIS MINIMISE THE LOSS DO NOT ADMIT LIABILITY 1. The Employer a) b) Address c) Industry or business Number Postal Code Town d) Policy No. Commencement date Expiry e) Are you registered with the Director of Occupational Health and Safety Yes No If yes, what is your Registration No. 2 The workman involved in employment injury a) Full name b) Physical address c) Permanent address d) Sex Male Female e) I.D. No. f) Activity undertaken at time of accident g) Workman s job description h) Status of employment Permanent Temporary Casual Under a contract If under contract, the name of the contractor (Kindly attach a copy of the contract)
Work Injury Benefit Claim Form www.resolution.co.ke j) When did the injured person enter your service k) Monthly or daily earnings at the time of the accident l) Has the workman filed a suit Yes No k) Has the workman filed any suit against you previously Yes No If yes, give details of suit k) Is the injured person still in employment Yes No If not, state date he/she ceased employment l) Was the injured workman suffering at the time of accident from ill health or bodily defect or infirmity of any description Yes No If yes, give details of suit 3. The accident a) Time Place b) At what time and from whom did you receive notification about the incident c) Has the incident been reported to the Director of Occupational Health and Safety Yes No If yes, date reported how (Submit documentary evidence with this form) d) Cause of accident e) Was the workman recorded on duty on the day of the accident Yes No f) What duty was the workman assigned at the time of the injury g) If injury was caused by machine: - State of machine and parts causing the injury - Was it fenced or guarded Yes No - Was the machine being cleaned Yes No - What was the general nature of the work going on - Was it in motion at the time of injury Yes No - Who was responsible for switching it ON/OFF - Who switched it on - His/her address - His permanent home address if different above - State exactly what the injured person was doing at the time of injury h) If injury not caused by machine(e.g. fire, free fall, carrying heavy objects, e.t.c) name the cause and give a brief description on how the workman got injured i) If motor vehicle is involved, indicate its registration number, policy number and name & address of the insurance company
4. The injury a) Nature of injury: Fatal Grievous Soft tissue Medical expenses only b) If fatal, give names of all dependants of the deceased workman if known c) Have the dependants informed the Director of Occupational Health and Safety Yes No If so, when and how d) Is the complaint an occupational disease Yes No If yes e) Was the claimant medically examined before commencing employment Yes No f) State to what extent the injured person is disabled and whether absolutely prevented from following his employment g) State whether the injuries are likely to cause any PERMANENT disablement h) the hospital/dispensary/private clinic where he has been treated following the accident i) Whether admitted Yes No If so, of admission of discharge j) Attendance as out-patient prior to and/or subsequent to hospitalization Yes No From To Was there a doctor s medical report Yes No (if yes, please forward copy) k) Amount expended on treatment l) Who paid for it m) Was the injury recorded on an occurrence book / injury register Yes No (If yes, please attach copy) yes, please attach copy) o) Has he/she resumed work Yes No When 5. OBSERVANCE OF INSTRUCTIONS a) Were there standing instructions/notices on how to do the assigned work Yes No b) Was the workman guilty of any misconduct or disobedience to such instructions or other orders or rules Yes No
Work Injury Benefit Claim Form www.resolution.co.ke If so, please give details c) Was the injured person under the influence of drugs or drinks at the time of accident Yes No d) Was the injured workman was provided with protective clothing/guards at the time of accident? E.g. gloves, gum boots, helmets, goggles, overalls etc Yes No If yes, state the items provided and was the workman utilizing the gear at the time of injury Yes No If not, why of supply Did the workman sign for the gear Yes No (If yes please attach a copy of the signed register) e) Was the workman found without protective gear at the time of accident Yes No If no, give reasons why f) Has his immediate supervisor brought to the attention of the insured workman the necessity of wearing protective clothing/guards when the former saw the latter without these guards at the time of commencement of his work but before the occurrence on the date of accident Yes No g) State through whose negligence this injury occurred 6. State the names, addresses (permanent and home) of the person(s) who witnessed this accident a) b) c) 7. Brief statement(s) of the above named person(s) who witnessed the accident when it occurred a b) c) (The above are factual to the best of my/our knowledge, information and belief)
The below part must be completed of employer Please stamp here using the signature of the employer or the company s authorized stamp STATEMENT OF WAGES The object of this statement is to ascertain the injured person s average monthly earning. Please therefore observe the following instructions carefully. Failure to do so will entail unnecessary correspondence and cause undue delay in the settlement of the claim. 1. If the injured person has been in Employer s service during a continuous period of more than one month immediately preceding the accident, the wages that have been paid or fallen due for payment, to him in each month of such period (not exceeding 12 preceding months in all) must be entered in this statement. 2. If the injured person has been in employer s service for less than one month,there must be entered in the statement the wages paid to another workmen employed on the same kind of work by the employer during the 12 months preceding the accident. MONTH WAGES BONUS VALUE OF FREE QUATRERS AND ALLOWANCES Total Total including Allowance a) Were the above stated wages paid, or fallen due to for payment to the injured person? Yes No If not, state to whom b) Was the injured person absent from work at any time, during the above stated period, for 114 or more consecutive days If so, give the following particulars; Absent for days from to Yes No RESOLUTION INSURANCE COMPANY LIMITED: Parkfield Place, Muthangari Drive, Off Waiyaki Way, Westlands P. O. Box 4469 00100, Nairobi, Kenya Tel: +254 20 2894 000 Mobile: +254 709 990 000, +254 730 199 000 Email: info@resolution.co.ke Website: www.resolution.co.ke RI/EB/FM/10 Rev.1 My Health, My Life, My Resolution