Workmen's Compensation Claim

BEFORE THE LEARNED COMMISSIONER FOR WORKMEN'S COMPENSATION, district

Compensation Petition No. _____ of year

claimant_name, S/O claimant_father_name, Age claimant_age, resident of claimant_address ... Petitioner/Claimant

VERSUS

employer_name, through its authorized officer, residing/situated at employer_address ... Respondent

CLAIM UNDER THE WORKMEN'S COMPENSATION ACT 1923

Respectfully submitted:

1. The Petitioner is a workman employed with the Respondent since employment_start_date in the capacity of designation at a monthly wage of Rs. monthly_wage.

2. On injury_date, while in the course of employment, the Petitioner sustained an injury_type arising out of and in the course of employment.

3. The injury was caused by cause_of_injury. The incident occurred at workplace_location during working hours.

4. Following the injury, the Petitioner received treatment from medical_facility and was certified to be incapacitated for work for a period of incapacity_period.

5. The Petitioner has suffered permanent disability as per Schedule I of the Workmen's Compensation Act 1923, with disability_type resulting in disability_percentage% disability.

6. A notice of the accident was submitted to the Respondent on accident_notice_date. The Respondent has not contested the claim or the nature of the injury.

7. The Petitioner is entitled to compensation under the Workmen's Compensation Act 1923 as per Schedule I or Schedule II of the said Act.

8. The compensation claimed is calculated as per the statutory formula under the Act, based on the monthly wages and the nature of injury.

9. The Petitioner has incurred medical expenses amounting to Rs. medical_expenses and has lost wages during the incapacity period.

10. The Petitioner submits that this claim is properly constituted and falls within the jurisdiction of the Commissioner for Workmen's Compensation under Section 20 of the Act.

PRAYER

It is, therefore, most respectfully prayed that this Honourable Commissioner may be pleased to:

(a) Allow the claim and direct the Respondent to pay compensation of Rs. compensation_amount to the Petitioner;

(b) Direct the Respondent to reimburse all medical expenses amounting to Rs. medical_expenses;

(c) Award interest on the compensation at the prescribed rate;

(d) Pass any such order or decree as deemed just and proper; and

(e) Grant such other relief as may be deemed appropriate.

VERIFICATION

Verified on solemn affirmation at verification_place on this _____ day of _____, year, that the contents of the above claim are true and correct to the best of my knowledge and belief and nothing material has been concealed therefrom.

_____________________________ claimant_name Petitioner/Claimant Through: _____________________________ counsel_name Advocate