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Republic of CyprusDepartment of Labour Inspection
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Notification of Accident
Ελληνικά
Notes:

i. If the information is not available use symbol "X"
ii. Name and last name of the employer must be written in capitals. In case of a legal person (e.g. company), please write the company΄s name as is registered in the Department of Companies and Official Receiver.


To whom Notification to be addressed:
*
1. Particulars of Employer:
1.1 Name (Note ii):
*
1.2 Registration Number (as registered in the Social Insurance Services):
*
1.3 Identity Card No (only for individual):
1.4 Telephone No:
*
1.5 Fax No:
1.6 E-mail address:
1.7 Postal Address (fill at least one of the two sections A or B)
A.
Street Name and Number (Note i):
*
Parish (Note i):
*
Suburb / Village / Town :
*
Postal Code of Street / Village:
*
District:
*
B.
P.O.Box:
*
Postal Code:
*
Area of P.O.Box
(Town / Suburb / Village):
*
2.0 Workplace
(Place (public / private) where accident happened)
2.1 Working Environment (e.g. production area, building site, agricultural area, office, store, school, hospital, residence, vehicle, motorway, etc):
*
2.2 Geographical address of work place
Street Name and Number (Note i):
*
Parish (Note i):
*
Suburb / Village / Town
*
District:
*
Other Details:
2.3 Economic activity (main economic activity of employer in the local unit where usually the victim is working – e.g. furniture making, building construction, food sales, tourist services, etc).
*
2.4 Number of persons employed in the local unit of the employer where the victim is working. In the case of a construction site report the number of the employees of the victim’s employer in this site. Total / Male / Female:
*
 Total

Male Female
3. Details of Injured Person:
3.1 Name (Note ii):
*
3.2 Home Address:
Street Name and Number (Note i):
*
Parish (Note i):
*
Suburb / Village / Town
*
Postal Code of Street / Village:
*
District:
*
3.3 Telephone:
*
3.4 Identify Card No / Passport No or A.R.C. Number for an alien:
*
3.5 Date of Birth:
*
 DD/MM/YYYY
3.6 Nationality (one of the three choices is compulsory):
*
Alien Nationality (in case of an alien):
3.7 Employment Status of Victim (one of the three choices is compulsory):
*
3.8 Sex: Male / Female
*
3.9 Occupation (during accident time e.g. building worker, carpenter, mining worker, office clerk, driver, company director, etc.):
*
4. Description of Accident:
4.1 Date of Accident:
*
 (DD/MM/YYYY)
4.2 Time of accident:
*
 (HH/MM)
4.3 State whether accident was fatal or not (one of the two options is compulsory):
*
4.4 Workstation of victim at the time of the accident (one at the two options is compulsory):*

4.5 How accident happened (brief description of how accident happened and what exactly the victim was doing during the time of accident):
*
4.6 Nature of injury and part of body injured:
*
5. Accident investigation by employer: YES/NO
5.1 Accident has been registered in the Accident Register of the employer according to the Management of Safety and Health at Work Regulations (one of the two choices is compulsory):
*
5.2 Accident report has been prepared (one of the two choices is compulsory): :
*
6. Declaration
(details below concern the employer if he is a private or in case of a company or an organization the responsible person who applies on behalf of the employer):
Name / Surname:
*
Position
(state whether director, office clerk, supervisor, etc):
*
Telephone No:
*
Fax No:
E-mail address:
7. Date of application: 24/05/2013
8. Documents, which are being submitted electronically:





Fields with * are mandatory.
This Notification Form will be signed in a later stage in case the Employer is been asked by the Inspector to do so.


© 2012 Republic of Cyprus, Ministry of Labour and Social Insurance