The Social Security (Bihar) Rules, 2026
Form II
Official text
Open in the official PDF (p. 82)
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[See rule 6 (2)]
Before the Employee Insurance Court at: ___________________________
Application No.: _______ of 20____
In the matter of:
Applicant:
1. Full Name: ___________________________________________
2. Age: __________________
3. Occupation: ___________________________________________
4. Full Postal Address: __________________________________
Details of Minor / Person of Unsound Mind (if applicable)
• The Applicant/Opposite Party is a minor/person of unsound mind.
• Name of Guardian / Next-of-Kin / Authorized Person: ______________________
• Age: __________________
• Full Postal Address: __________________________________
Versus
Opposite Party:
1. Full Name: ___________________________________________
2. Full Postal Address: __________________________________
Particulars of the Application
1. Cause of Action
The facts constituting the cause of action are as follows:
________________________________________
Date on which cause of action arose: ____ / ____ / ______
________________________________________
2. Jurisdiction
The Applicant submits that this Hon’ble Court has jurisdiction to entertain this application
because:
________________________________________
3. Relief Claimed
The Applicant respectfully prays that this Hon’ble Court may be pleased to:
________________________________________
And pass any other order(s) deemed fit and proper in the interest of justice.
________________________________________
Verification
I, ____________________________, the Applicant above named, do hereby verify that the
contents of this application are true and correct to the best of my knowledge and belief.
Place: __________________
Date: ____ / ____ / ______
Signature of Applicant: ___________________________
Name: ___________________________________________
List of Enclosures (if any)
Signature of Applicant
(verification by the applicant)
The statement of facts contained in this application is to the best of my knowledge and
belief, rue and correct.
……………………….
Signature
Date ………….