Kl

1. L&T Construction, Water & Effluent Treatment IC
Visitor Indemnity Form
Doc No: IM-06-F Revision No: 06 Date: 30/07/2021 Page 1 of 4 SofeArnz
oject/Site/location Pllef Paw
Date of visit 6/1/9 2
Purpose of visit
Po Boaaed (oad
CompanyName Pandtal Pot CRII4Es220)
Contact
number26642
S3 7
L.(NAME)
hereby declare that I am physically fit and currently not under any prescribe medication.
I agree to adhere to the L&T Construction, WET IC's In-House Rules and Regulation
on Environmental, health arid safety and other related requirements that may apply. I
further agree to always wear the mandatory Personal Protective Equipment (PPE)
within the project work area and always remain with my guide.
Bhoso
(NRIC/FIN/PASSPORTNO.)
Tunderstand that failure to adhere with the instructions given during the EHS Induction
training will be resulted to my own risk, ill health, injury, and incident.
l agree not to hold the main occupier L&T Construction -Water Effluent Treatment 1C,
liable for any accountability,Iharm or loss of whatsoever nature that may occur to me.
undertake to refrain from performing, supervise and or command instruction during any
work activity/process/execution and shall alert my host of any unsafe act or unsafe
condition, which I may encountered or foresee.
Iread and understood the site information brochure, site organizational chart and site
map provided. I understood the emergency evacuation procedure and assembly point,
where I have to evdcuate in case of any emergency and natural calamity.
Signature
EMERGENCY CONTACT PERSON
Relationship: sotur
Name
Contact No:807607229
Realize the Vision of "Zero Harm" byImproving EHS Performance through meaningful Engagement of Workforce
EHS Department- Ha, NET IC Larsen and Toubro Limited, Construction. AllRights Resenved. viEW ENS