Labour Application Under Workmen S Compensation Act For Compensation By 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____