Form B-44 - Employer'S Report On Accident At Work
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1
2The National Insurance Act, 1972
Commonwealth of The Bahamas
E
’
R
A
W
MPLOYER
S
EPORT ON
CCIDENT AT
ORK
Instructions for Completing This Form
1. The National Insurance Regulations require that all accidents be reported by the employer. The employer must
investigate the accident before completing this form.
2. The entire form is to be completed by the employer or his agent.
3. Submit the form immediately or within one (1) month of the date of accident to the nearest National Insurance
Local Office to avoid delay in the processing of the claim; failure to submit this form within the specified
timeframe may result in the imposition of penalties (fines of up to $500).
SECTION A: EMPLOYER INFORMATION
Business Name: ______________________________________________________________________
Registration No.
Street Address: _______________________________________________
P.O. Box: _____________
Tel. No.: ___________________
E-Mail: ________________________________________________
Nature of Industry of Business: __________________________________________________________
SECTION B: INJURED EMPLOYEE’S INFORMATION
Name: _________________________________________
N.I. No.
Street Address: _______________________________________________
P.O. Box: _____________
Tel No.: _____________________ (h) ______________________(w) _____________________ (c)
E-Mail: ______________________________________________________
Occupation: __________________________________________________
What are the duties of the employee: ____________________________________________________
Date of Accident: ______ / ______ / ________ Time: __________ a.m./p.m.
dd
mm
yyyy
Place of Accident: ____________________________________________________________________
Description of apparent Injury/incapacity: _________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Was the person:
( a ) Employed by you on the day of the accident?
Yes
No
(b) A Partner, Director or Sub-Contractor?
Yes
No
(c ) Involved in an accident that took place while working on
the date mentioned?
Yes
No
What hours was the person expected to work that day? From______a.m./p.m. to:______ a.m./p.m.
SECTION C: REPORT OF ACCIDENT
1. When was the accident first reported? Date: ______ / ______ / ________ Time: ________a.m./p.m.
dd
mm
yyyy
2. (a) Was the accident reported to you?
Yes
No
(b) If not, to whom (please print the name and position of the person):
____________________________________________________________________________
3. If the accident was not reported on the day it happened, state why: _________________________
_______________________________________________________________________________
_______________________________________________________________________________
Form B-44 [revised 06/2011]
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