Labour Application Under Workmen

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____________ 200__________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____