Form XVI

[See sub-rule (1) (2) of Rule 36]

Application for Compensation by Workmen

To

The Competent Authority for Workmen's

Compensation

……………………………….

…………… Residing at...………………….

Applicant

Verses

…………… 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. The cause of the injury

was (here insert briefly in ordinary language the cause for the injury) ……

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

(3) The monthly wages of the applicant amount to Rs. the applicant

is over/under the age of 15 years.

*(4) (a) Notice of the accident was served on the………………. Day of

(b) Notice was served as soon as practicable................................

(c) Notice of the accident was not served (on due time) by reason of

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

(a) Half-monthly payments of Rs. …………………. from the day of

20………….to ……….

(b) A lump-sum payment of Rs............................

(6) The applicant has taken the following steps for settlement by agreement,

namely ……………….to settle but it has proved impossible to settle the

question in dispute because...................................................................

*You are, therefore, requested to determine the following questions in

dispute, namely:

(a) Whether the applicant falls within the meaning of workman under the

code.

(b) Whether the accident arose out of or in the course of the applicant's

employment.

(c) Whether the amount of compensation claimed in

reasonable/due, or any part of that amount.

(d) Whether the opposite party is liable to pay such compensation

as is due etc., (as required).

*Strike out of the clauses which are not applicable.

Date: Applicant