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Employees Compensation Assistance Ordinance (Cap. 365)

Section 16

Application for unpaid Employees’ Compensation from the Fund

WARNING: Under s.40 of the Employees Compensation Assistance Ordinance, any person who in providing

information makes any statement or, with intent to deceive, produces any document or record or makes

any declaration which he knows to be false or does not believe it to be true in a material particular

commits an offence and is liable to a fine of HK$100,000 and to imprisonment for 12 months.

(For assistance in completing this form, please contact the Secretariat of the Fund Board at 2116 5684.)

To: The Employees Compensation Assistance Fund Board

Part I : Particulars of Employee (* delete whichever is inappropriate)

Name: (in English) Mr/Mrs/Miss/Ms* (in Chinese)

Date of Birth: Identity Card No.:

Telephone No.:(Home) (Mobile/Office)

Address: Date of injury/death*:

Working section and position held:

Address of the place of accident: _____________________________________________________________________

Part II : Particulars of Applicant (Not applicable if same as Part I)

Name: (in English) Mr/Mrs/Miss/Ms* (in Chinese)

Date of Birth: Identity Card No.:

Relationship with employee:

Address:

Telephone No.:(Home) (Mobile/Office)

Part III : Particulars of Employer

Name: (in English) (in Chinese)

Name of person-in-charge: (in English) Mr/Mrs/Miss/Ms*

Name of person-in-charge: (in Chinese) Telephone No.:

Address: Business Registration Cert. No.:

Insurance Cover: Yes / No * Policy No.:

Name, address & telephone no. of insurance company:

Part IV : Particulars of Insurance Policy Holder (Not applicable if same as Part III)

Name: (in English) (in Chinese)

Relationship with employee: Telephone No.:

Address: Policy No.:

Name, address & telephone no. of insurance company:

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Part V : Particulars of Application

‧ Periodical payments $

‧ Employees’ compensation for permanent incapacity

‧

$

‧ Employees’ compensation for death $

$

$

‧ Medical expenses

‧ Costs of prostheses or surgical appliances

‧ Others (please specify) _____________________________________ $

Total: $

Part VI : Evidence in support of the Application

(a) Evidence to prove the entitlement of payment (put a “” in the appropriate items):

judgment / order of the court

Certificate of Compensation Assessment (Form 5) Certificate of Review of Compensation Assessment (Form 6)

Certificate of Medical Expenses

employment contract

wage records / proof of wage rates

others (please specify)

(b) Evidence to prove that all reasonable legal and financially viable proceedings /

steps for recovery of payment have been taken against the employer and the

principal contractor (as the case may be) (please attach a separate sheet if the

space below is insufficient):

(c) Evidence to prove that all reasonable legal and financially viable proceedings /

steps for recovery of payment have been taken against the insurer (please attach

a separate sheet if the space below is insufficient):

For official use only

I declare that I conscientiously believe that the information and statements given above are true.

I understand and accept that the information given above will be provided to members of the Employees Compensation

Assistance Fund Board, the Board’s legal advisers/representatives, the concerned Government Departments and parties,

the court, all kinds of agents engaged by the Board to carry out investigation into the claim, and/or any parties or

entities referred to in any documents used in the course of legal proceedings that relates to the claim for payment from

the Fund for the purposes of processing of the application and/or carrying out of investigation therefor. The information

given above will be used for the purpose of assisting the Board in carrying out its functions as stipulated in Part IV and

Part V of the Employees Compensation Assistance Ordinance (Cap. 365); and it will also be used for the purpose of

conducting or defending legal proceedings that the Board is empowered to take part pursuant to Cap. 365.

Signature:

Name:

Date:

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Explanatory Notes:

(1) Subject to the statutory criteria under the Employees Compensation Assistance Ordinance (the

ECAO) in relation to applications under section 16, no application under that section shall be made to

the Employees Compensation Assistance Fund Board (the Board) unless and until the employer

concerned has become liable for the payment of an amount of employees’ compensation to the

applicant. You may refer to subsection 16(2) of the ECAO for the circumstances under which an

employer is to be regarded as liable for the payment of an amount of employees’ compensation.

(2) No interest is payable on the amount which the Board determines to render assistance pursuant to an

application under section 16 of the ECAO –

(i) where the application concerned is made after the expiration of 180 days after the date on which

the employer concerned becomes liable for the payment of the amount, in respect of the period

beginning on that expiration and ending on the date on which the application is so made; and

(ii) in respect of the period beginning on the date the application concerned is made and ending upon

the expiration of 180 days after that date.

(3) The interest-free period referred to in 2(ii) above shall not start to run until the employer concerned has

become liable for the payment of an amount of employees’ compensation to the applicant

notwithstanding that an application is made to the Board before that day.

Personal Information Collection Statement

The information given above will be provided to members of the Employees Compensation Assistance Fund

Board, the Board’s legal advisers/representatives, the concerned Government Departments and parties, the

court, all kinds of agents engaged by the Board to carry out investigation into the claim, and/or any parties or

entities referred to in any documents used in the course of legal proceedings that relates to the claim for

payment from the Fund for the purposes of processing of the application and/or carrying out of investigation

therefor. The information given above will be used for the purpose of assisting the Board in carrying out its

functions as stipulated in Part IV and Part V of the Employees Compensation Assistance Ordinance (Cap. 365);

and it will also be used for the purpose of conducting or defending legal proceedings that the Board is

empowered to take part pursuant to Cap. 365.

Your provision of all the personal data requested in the application form is obligatory. Your application may be

rejected or may not be considered if you fail to provide all information as requested or if it is not clear from

your statements that you are entitled to apply to the Board for assistance under section 16 of Cap. 365.

You are required to notify the Board if there are any subsequent changes to the information provided after

submission of the application form.

For correction of or access to personal data after submission of the application form or other enquiries

about the application, please contact the Secretariat of the Board (Address: 33/F, Morrison Plaza, 9 Morrison Hill Road, Wanchai, Hong Kong) or the legal representatives appointed by the Board.