Form 4a
Form 4a
Form 4a
(See Regulation 8)
From
Name
Postal address
District
State
PIN
Mobile Number
Fax number
Email ID
To:
Sir,
I have to furnish the following particulars of fatal/serious accident/ dangerous occurrence(*) which
occurred at
1. Name of Mine
2. Name of Owner
3. Mine Code (nnnnnn):
4. Labour Identification Number (LIN)
5. Date of accident (DD/MM/YYYY)
6. Time of Accident (hhmm)
7. Particulars of the mine:
7.1 Mineral
7.2 Village/area/road
7.5 District
7.6 State
8. Postal address of
owner 8.1
Village/area/road
8.4 District
8.5 State
8.6 PIN
9.10 Seam
(nn) (hhmm)
Killed
1.
2.
Seriousl
y injured :
1.
2.
Particulars in respect of every person killed or injured in Form IV-B are enclosed / shall be forwarded within a
week.
Yours faithfully,
Signature:
Designation
(Owner/agent/manager)
Date:
Place:
0334 Conveyors
0335 Dumpers
0500 Explosives
0600 Electricity
PLACE CODE
1 Below ground
2 Opencast
3 Above ground
WORKINGS CODE
1 Development
2 Longwall
3 Depillaring
4 Coal bench
5 O/B Bench
6 Waste Dump
9 Others
DESIGNATION CODE
ACTUAL
CODE DESIGNATION
20 Management
41 Loaders
42 Support Personal
43 Dresser
44 Shotfirer
59 Trammer
60 Fitter
71 Dumper Operator
79 Other Operator
99 Any Other