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.........20............received personal injury by accident arising out of and in the course of his employment.
2. The cause of the injury was (here insert briefly in ordinary language the cause of injury)	
3. The applicant sustained the following injuries, namely:
The monthly wages of the applicant amount to Rs……….is over................... 
The applicant……………the age or 15 years under
4.(a) Notice of the accident was not served on the……….day.................. of.......................	
Notice was served as soon as practicable.
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……20…… 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;
etc. (as required).
Dated	20		Applicant