Form XXXI

{See sub-rule (2) of Rule 72}

Application for Compensation by employee

To,

The Competent Authority for Employee’s Compensation

……………………………………..

(Applicant residing at)

Versus

……………………… (Opposite Party residing at)

Sir/Madam,

It is hereby submitted that: -

1. The applicant, an employee, employed by (contractor with) the opposite party on the …………. day of

………. 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 of Rs. The applicant is over/under the age of 15

years.

4. It is submitted that-

2.

a. Notice of the accident was served on the …………..day of…………. 20…….

b. Notice was served as soon as practicable on the …………..day of…………. 20…….

c. Notice of the accident was not served (in due time) by reason of-

5. The applicant is accordingly entitled to receive: -

2.

a. half monthly payment of Rs. From

the _ day of 20 to day of 20 _

2.

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 question in dispute because

You are therefore requested to determine the following questions in dispute, namely: --

2.

a. Whether the applicant is a workman within the meaning of the Code;

b. Whether the accident arose out of or in the course of the applicants employment;

c. Whether the a amount of compensation claimed is due, or any part of that amount;

d. Whether the opposite party is liable to pay such compensation as is due;

e. any other issues (as required)

Date: _20

Place:

Signature/ Thumb impression

of the applicant

* strike out of the clauses which are not applicable.