Application under Workmen’s Compensation Act for Order to Deposit Compensation

Application under Workmen’s Compensation Act for Order to Deposit Compensation

It is hereby submitted that—

1. ………………a workman employed by (a contractor with) the opposite party on the …………… day of ………… 19……… received personal injury by accident arising out of and in the course of his employment resulting in his death on the ……… day of ………… 19………. The cause of the injury was (here insert briefly in ordinary language the cause of the injury) …………

is a

2. The applicant(s)   –––––––    dependant(s) of the deceased workman

are

being his ………………………

3. The monthly wages of the deceased amount to Rs. ………….

over

4. The deceased was  ––––––  the age of 15 years at the time of his death.

under

5.         (a)  Notice of the accident was served on the …………… day of …………

(b)  Notice was served as soon as practicable.

(c) Notice of the accident was not served (in due time) by  reason

…………… of ………….

6. The deceased before his death received as compensation the total sum of Rs. .                  ……………….

is

The applicant(s)   ––––––   accordingly entitled to receive a lump sum payment

are

of Rs. ………….

You are, therefore, requested to award to the applicant(s) the said compensation or any other compensation to which he may be entitled.

Dated …………                                                                                       Applicant(s)

Dated the ………… day of ……… 19 ……

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