FORM A
[Rule 3]

Whereas a claim for compensation has been made by (applicant) against ___________ and the said applicant has claimed that he is entitled to file an application under clause (b) or (c) of section 21(1) of the Workmen's Compensation Act, 1923;
And where as the undersigned is satisfied that the said applicant is entitled to file the aforesaid claim;
Now, therefore, the Commissioner for Workmen's Compensation /Government of ___________ is hereby given notice that the undersigned proposes to settle the claim of the applicant as provided under the Act.
Dated:
Commissioner