Claim for Fatal Accident Compensation

TO THE COMMISSIONER FOR WORKMEN'S COMPENSATION district INDUSTRIAL COURT city

CLAIM FOR FATAL ACCIDENT COMPENSATION

Claim No. claim_number of year

Claimant(s): claimant_name, claimant_address Relationship to Deceased: relationship Versus Employer/Respondent: employer_name, employer_address Insurance Company: insurance_company, insurance_address

1. The claimant(s) hereby make this claim for fatal accident compensation under Section 22 of the Workmen's Compensation Act 1923 in respect of the death of deceased_name who was employed by employer_name.

2. Name: deceased_name Age: deceased_age years CNIC No: deceased_cnic Designation: deceased_designation Salary: PKR monthly_salary per month Length of Service: service_years years and service_months months Date of Joining: joining_date

3. The deceased worker met with a fatal accident on accident_date at accident_location, accident_city. The accident occurred while the deceased was engaged in the course of employment and under the direct instructions of the employer.

4. First Aid Provided: The deceased was taken to hospital_name where he/she was admitted with injuries. Medical examination and treatment were provided, but the deceased succumbed to the injuries on death_date at death_time.

5. According to the post-mortem examination report dated postmortem_date, a copy of which is attached as Annexure-A, the cause of death was cause_of_death resulting directly from the injuries sustained in the workplace accident.

6. Notice of the accident was given to the employer on notice_date as required under the Act. The employer has not disputed the fact of the accident or the causal connection between the accident and employment. The employer's workers' compensation insurance policy No. policy_number issued by insurance_company with effect from policy_effective_date covers this claim.

7. The claimant(s) are the dependants of the deceased as follows:

8. These persons were wholly or partly dependent on the deceased's income for their maintenance.

9. Under Schedule IV of the Workmen's Compensation Act 1923, the compensation payable is percentage_of_monthly% of the monthly salary for a period of compensation_period months, or a lump sum of PKR lump_sum_amount, whichever is greater.

10. Calculation: - Monthly Salary: PKR monthly_salary - Multiplier (from Schedule IV): multiplier_factor - Total Compensation: PKR total_compensation - Less: Advance Payments (if any): PKR advance_payments - Net Amount Due: PKR net_amount_due

11. The following documents are attached in support of the claim:

PRAYER

12. (a) Copy of death certificate issued by death_cert_issuing_authority; (b) Post-mortem examination report; (c) Accident report from the employer; (d) Medical records from hospital_name; (e) Wage slips and salary proofs for salary_proof_months months; (f) Birth certificates of dependant children; (g) Affidavits by dependants confirming their relationship and dependency; (h) Copy of workers' compensation insurance policy.

WHEREFORE, the claimant(s) respectfully pray that this Hon'ble Commissioner may be pleased to: (a) Accept this claim for fatal accident compensation; (b) Award compensation to the claimant(s) in the sum of PKR total_compensation plus interest at the rate of interest_rate% per annum from the date of death to the date of payment; (c) Direct the Respondent and/or the Insurance Company to deposit the awarded amount in court within payment_days days; (d) Pass such further orders as this Hon'ble Commissioner may deem fit and proper in the circumstances of the case.

VERIFICATION

I/We, the undersigned claimant(s), do hereby solemnly declare that the contents of the above claim are true and correct to the best of my/our knowledge, information, and belief. I/We make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Ordinance, 1960.

Signed: ___________________ Name: claimant_name Relationship: relationship Date: filing_date Place: filing_place Witness: ___________________