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 law contractor with) the opposite party on the……….day of ……. …….. 19…….., received personal injury by accident arising out or and in the course of his employment.
The cause of the injury was (here insert briefly in ordinary language the cause of the injury)………….
 .......... ……… ……… …….. ……… ………
…….. ……… ……… …….. ……… ………
......... ……… ……… …….. ……… ………
......... ……… ……… …….. ……… ……..
2. the applicant sustained the following injuries, namely _
......... ……… ……… ……… ……… ………
……. ……… ……… ……… ……… ………
……. ……… ……… ……… ……… ………
……. ……… ……… ……… ……… ………
……. …….. ……… ……… ……… ………
(3) The monthly wages of the applicant amounts to ……………………………. the applicant is over/under the age or 15 years.
*(4)     (a) Notice or the accident was served on the day or
(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 form 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 ... .......... …….. ……. ……. …….
You are therefore requested to determine the following questions in dispute, namely-
(a) Whether the applicant is a workman within the meaning of the Act;
(b) Whether the accident arose out of or in the course of the applicant’s employment;
(c) Whether [lie amount or compensation claimed is due, or any part or 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.