APPLICATION UNDER WORKMEN'S COMPENSATION ACT FOR COMPENSATION BY WORKMEN [CD1]
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………
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