Workmen Compensation Application

BEFORE THE COMMISSIONER WORKMENS’ COMPENSATION COURT, _________

_________ son/daughter of _________
Resident of _________, _________

….Applicant/Claimant

VERSUS

1-    _________ Through _________
2-    _________, _________

….Respondents

Application Under the Workmen’s compensation Act For the grant of compensation of _________/-

Respectfully Showeth:-

1-    That applicant/claimant _________.
2-    That since _________.
That on _________.
3-    That _________.
4-    That the respondents _________.
That Although _________.
PRAYER:
It is, therefore, prayed that in view of the forgoing facts and circumstances this hon’ble court may kindly be pleased to:
i)    Pass an order _________.
ii)    Pass an order directing _________.
iii)    Any other relief, which this Hon’ble Forum may deem fit and proper, be passed in favour of the complainant and against the respondents.
Applicant/Claimant
Through Authorised Representative
_________, Resident of _________,
District _________, _________

VERIFICATION:   

Verified that the contents of Paras No. _________ to _________ of the above application are true and correct to best of my knowledge and belief and nothing is false and untrue. Last Para is the prayer
Verified at _________ on _____________

Applicant/Claimant