Form I

(See Rule 5)

Appeal to Employees' Insurance Court

To,

The Authority,

(Appointed under the Code on Social Security, 2020)

……………………………………………(Address)

Sir,

I…….., the undersigned, employee of……....… (Name and full address of the

establishment). Feel aggrieved by the order of ......................................... under sub section

7(a) of section 37 for the reasons attached hereto, prefer this second appeal under sub-section

7(b) of section 37 and request that the said ................. be ordered

.............................................................................................

A copy of the order of .......................................................................................... in

this behalf is enclosed.

Signature or thumb impression

of the Aggrieved person

Signature of an Attester in case the person

is not able to sign and affixes thumb impression.

Date .......................