APPLICATION UNDER WORKMEN'S COMPENSATION ACT FOR COMPENSATION BY WORKMEN
To the Commissioner for Workmen's Compensation ............resident at............
.........................................Applicant
versus
................................................Opponent party
resident at............
It is hereby submitted that—
1. The applicant, being workman employed by (a contractor with) the opponent party on the ............ day of............ 20..........got accidental personal injury due to and in the duration of his employment.
The reason of injury was (here give shortly in ordinary language the reason of injury)...............
2. The applicant suffered the following injuries, namely:
3. The monthly wages of the applicant being Rs........
The applicant is over/under the age of 15 years.
4.
(a) Notice of the accident was not served on the ..................... day of................
(b) Notice was served as soon as possible.
(c) Notice of accident was not served (in due time) on account of................
The applicant is hence bear right to receive—
(a) half-monthly payment of Rs........... from the ............. day of......... to...............
(b) a lump sum payment of Rs. ..................
5. The applicant has followed steps as below for getting a decision by agreement, namely—
but controverted question were not decided despite efforts because............
You are hence requested to determine the following questions in controversy namely—
(a) If applicant is a workman by the interpretation of Act;
(b) whether accident occurred during the applicant's employment;
(c) If the amount of compensation claimed falls due, or any portion of that amount;
(d) If opponent party is responsible to pay such indemnification as is due;
(e).................................................................................................................................................................................................... etc. (as needed).
Dated……..
Applicant………
