Application Report For Industrial Injury Identification

* * District Labor and Social Security Bureau:

The center of social labor insurance in XX city is:

We have the name of this unit, the name of the sex x * birth date * * * * * * * * nationality * * * identity card number * * * * * * * * * * * home address * * * * * * * * * * * * *

Enter time: * * * * * * * * * * * *

Participate in industrial injury insurance time * * * * * * * * *

My contact number is x x x x x x x x x x x

Injury facts and experience:

Treatment hospitals:

Payment of work-related injury insurance: work injury insurance has been paid until the end of the year.

This report, please give verification to identify work-related injuries.

Applicant unit (official seal):

Date of application: date, month and date