FORM G [See Rule 20] Application for Order to Deposit Compensation To The commissioner For Workmen's Compensation ....................... ....................... ...... residing at ......... Applicant, Versus ...... Residing at ......... Opposite party. It is hereby submitted that (1) .................. a workman employed by (a contractor with) the opposite party on the ...... Day of ..... 19...... Received personal injury by accident arising out of land in the course of his employment resulting in his death on the ...... Day of ..... 19, The cause of the injury was (here insert briefly in ordinary language the cause of this injury) .................................... ....................................... (2) The applicant(s) is /are Dependant (s) of the deceased workman being his..... (3) The monthly wages of the Deceased amounts to Rs.... The deceased was over/under the age of 15 years at the time of his death. *(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 deceased before his death received as compensation the total sum of Rs... 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. Dated.......19... Applicant. Page 90 of 151 * Strike out the clauses which are not applicable. The applicants state as follows; 1. The applicants whose names and permanent address appear in the attached schedule are person employed in the/ on the/factory/industrial establishment entitled and resides at ....... The address of the applicants for service of all notices and process is: 2. X,Y,Z the opposite party, is the person responsible for the payment of wages under Section 3 of this Act, and his address for the service of all notices and process is: ...................................... (3) The applicants' wages have not been paid for the following wage-period (s): .................................... (4) The applicant estimates the value of relief sought by them at the sum of Rs..... (5) The applicant pray that a direction may be issued under Section (3) of Section 15 for: (a) Payment of the applicants' delayed wages as estimated ...... Or such greater or lesser amount as the Authority may find to be due. (b) Compensation amounting to Rs.....] The applicants certify that the statement of facts contained in this application is to be the best of their Knowledge and belief, accurate. Signature or thumb impression of two of the applicants, or legal practitioner, or an official of a registered trade union duly authorized. Page 91 of 151 SCHEDULE S. No. Name of Applicant Permanent address_______ 1 2 3 Page 92 of 151
