The Uttar Pradesh Code on Social Security Rules, 2026
Form XXII
Official text
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{See sub-rule (2) of Rule 65}
Statement to be submitted by the employer to Competent Authority in Fatal accidents
To,
The Competent Authority for Employee’s Compensation,
……………………………….
Sir/Madam,
1. In reply of your notice dated ………… of ……… 20……. , which was received by me on ….. 20……., it is
submitted that residing at employee over/ under 15 years of age and employed in ………………….. met
with an accident on the day of …………. 20………… as a result of which he died on the ….. day of …..
20…. The monthly wages of the deceased amounted to rupees …………
2. The circumstances in which the deceased met his death were as follows–
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
3. I admit liability to pay as compensation on account of the deceased’s death with the amount of rupees
…………………. which was/ will be deposited with you on or before the ……………. day of …………….
20…………
4. I disclaim liability to pay compensation on account of the deceased’s death on the following grounds-
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
Name of deceased employee:
Name of establishment:
Date:
Place:
Signature of employer Seal