The Uttar Pradesh Code on Social Security Rules, 2026
Form XXXII
Official text
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{See sub-rule (2) of Rule 72]
Application for order to Deposit Compensation
To,
The Competent Authority for Employee’s Compensation
……………………………………..
………………….….. (Applicant residing at)
Versus
……………………… (Opposite Party residing at)
Sir/Madam,
It is hereby submitted that: --
1. A workman employed by (a contractor with) the opposite party
on the day of _20 , received personal injury by accident arising
out of an in the course of employment resulting in his death on the day of 20 he cause of injury
was (here insert briefly in ordinary language the cause of the injury) .
2. The applicant(s) is/are dependant(s) of the deceased workman being his _.
3. The monthly wages of the deceased amount Rs. . The deceased was
over/under the age of 15 years at the time of his death.
4. It is submitted that-
a. Notice of the accident was served on the day of .
b. Notice was served as soon as practicable on .
c. Notice of the accident was not served (in due time by reason of) .
5. The deceased before his death received as compensation the total sum of Rs................... .
6. The applicant(s) is/are accordingly entitled to receive a lump sum payment of Rs. .
You are, therefore, requested to award to the applicant the said compensation or any other compensation to
which he may be entitled.
Date: 20
Place:
Signature/ Thumb impression
of the applicant
strikeout of the clauses which are not applicable.