Application under Workmen’s

Application under Workmen’s

Compensation Act for Compensation by Workmen

To the Commissioner for Workmen’s Compensation …………

residing at …………………………                                                Applicant

versus

residing at …………                                                                   Opposite party

It is hereby submitted that—

1. The applicant, 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.

The cause of the injury was (here insert briefly in ordinary language the cause of injury) ……………

………………………………………………………………………………………………………..

………………………………………………………………………………………………………..

2. The applicant sustained the following injuries, namely:

………………………………………………………………………………………………………..

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

is over

The applicant  ––––––  the age of 15 years.

under

4.         (a)        Notice of the accident was not 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 ………….…

The applicant is accordingly entitled to receive—

(a)  half-monthly payment of Rs. ………… from the ……………… day of ……… 1999 to ……………

(b)  a lump sum payment of Rs. ………………

5. The applicant has taken the following steps to secure a settlement by agreement, namely—

but it has proved impossible to settle the questions in dispute because …………

You are, therefore, requested to determine the following questions in dispute, namely—

(a)  whether the applicant is a workman within the meaning of the Act;

(b) whether the accident arose out of or in the course of the applicant’s employment;

(c) whether the amount of compensation claimed is due, or any part of that amount;

(d)  whether the opposite party is liable to pay such compensation as is due;

(e)  etc. (as required).

Dated ………… 19 ……                                                                          Applicant