Application Under Workmen’s Compensation Act For Compensation By Workmen
Application Under Workmen’s Compensation Act For Compensation By Workmen Deed Format
To the Commissioner for Workmen’s Compensation …………
residing at ………………………… Applicant
versus
residing at ………… Opposite party
It is hereby submitted that—
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).
Application Under Workmen’s Compensation Act For Compensation By Workmen Deed Format
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