FORM G
[See rule 20]
APPLICATION FOR ORDER TO DEPOSIT COMPENSATION

To the Compensation for Workmen’s Compensation…….…….…….....residing at…….. ……… ……… ………            applicant,
versus
..........…..………………residing at..........…….…….. …….. ……… ….. .opposite party.
It is here by 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 the 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 or
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
*Strike out the clauses, which are not applicable.