Form XXI

{See sub-rule (1) of Rule 65}

Notice to be sent by the competent authority in fatal accidents

Whereas I have received information that ………………an, employee employed by

you in .........…has died, as a result of an accident arising out of and in the course of

employment, I hereby, require you in accordance with sub-section (1) of section 88 of the Code

to submit to me within thirty days of the receipt of this notice, the enclosed Form with the

particulars, required in paragraph 1 and 2 and the particulars required in either paragraph 3 of

paragraph 4, duly filled.

In the event of your admitting liability to pay compensation, the necessary deposit must

under sub-section (1) of Section 88 of the Code be made within thirty days of the receipt of this

notice.

Date :

Competent Authority

Seal