Form XXI

(See Rule 31(1))

Application for Compensation by employee

To

Competent Authority for Employee's Compensation………residing at, ………… applicant,

Versus

residing at, ................................ opposite party.

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 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 (in due time) by reason

of .............

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

(a) Half-monthly payment of Rs………from the........day of .............20......,

to........day of………20…

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

(6) 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 an employee within the meaning of the code;

(b) whether the accident arose out of or in th·ecourse of the applicant's employment;

(c) whether the whole or any part of the amount of compensation claimed is due;

(d) whether the opposite party is liable to pay such compensation as is due;

(e) etc. (as required).

Dated .............20…………………… Applicant