FORM F [See Rule 20] Application for Compensation by workman To The Commissioner For Workmen's Compensation ....................... ....................... ...... residing at ......... Applicant, Versus ...... Residing at ......... Opposite party. It is hereby submitted that: (1) The applicant, a workman employed by (a contractor with) the opposite party on the ...... day of ..... 19...... 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 this injury) .................................... ....................................... (2) The applicant sustained the following injuries, namely:.................................... .................................... (3) The monthly wages of the applicant amounts 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 19... to . (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................................ Page 88 of 151 You are therefore requested to determine the following questions in dispute, namely: (a) Whether the applicant is a workmen within the meaning of the Act; (b) Whether the accident arose out of or in the course of the applicant's employment; (c) Whether the amount of compensation claimed is due, or any part of that amount; (d) Whether the opposition party is liable to pay such compensation as is due; (e) etc. (as required) Dated...... 19... Applicant. * Strike out the clauses which are not applicable. Page 89 of 151
