Form XXVII

[See rule 59(1)]

Application for Compensation

To

The Competent authority for Employee‘s Compensation.

Applicant residing at

Versus

OppositeParty residing at

It is hereby submitted that:-

(1) The applicant, an employee 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.

The cause of the injury was (here insert briefly in ordinary language the cause of the injury)

(2)The applicant sustained the following injuries namely:--

(3) The monthly wages of the applicant amounttoRs. . The applicant is over/under the age of 15

years.

(4 ) (a) Notice of the accident was served on the ___dayof____

(b) Notice was served as soon aspracticable.

(c)Notice of the accident was not served (in due time) by reasonof.

(5) The applicant is accordingly entitled to receive:--

(a) half monthly payment of Rs. from the 20 to ___

(b) a lump sum payment ofRs.

(6)The applicant has taken the following steps to secure a settlement by agreement, namely,-

___butithasprovedimpossibletosettlethequestionindisputebecause .

*You are therefore requested to determine the following questions in dispute, namely: --

(a)Whether the applicant is an employee within the meaning of theCode;

(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 isdue;

(e)etc., (asrequired)

Date 20.

Applicant

* Strike out the clauses which are not applicable.