WORKMEN`S COMPENSATION ACT 1923

The Act aims to provide workmen / or their dependents some relieI in case oI
accidents arising out and in the course oI employment and causing either death or
disablement oI workmen. Payment oI compensation is made compulsory
/mandatory by the employer Ior employment injuries / deaths.











106






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7
FORM - A
|See Rule 6 (1)|

DEPOSIT OF COMPENSATION FOR FATAL ACCIDENT
[Section 8 (1) of the Workmens Compensation Act, 1923]

Compensation amounting to Rs. is hereby presented Ior
deposit in respect oI injuries resulting in the death oI the work man, whose
particulars given below, which occurred on ......

Name
Father`s name in case oI
Married woman and widow.)
Caste
Local address
Permanent address
His / Her monthly wages are estimated at Rs.
He / She was over / under the age oI 15 years at the time oI his / her death.
2. The said workman had, prior to the date oI his / her death received
the Iollowing payments, namely:-

Rs. on Rs. on

Rs. on Rs. on

Rs. on Rs. on
Amounting in all to Rs.
3. An advance oI Rs. has been made on account oI
compensation to ......... being his / her dependant.
4. * I do not desire to be made a party to the proceedings Ior
distribution oI the aIoresaid compensation.

Dated ......20 Employer


Now, thereIore, the Commissioner Ior Workmen`s Compensation ...... /
Government oI ........ is hereby given notice that the undersigned proposes
to settle the claim oI the applicant as provided under the Act.

|
Dated: Commissioner

* An Employer desiring to be made a party to the proceedings should strike out the work 'do not.
108

FORM -II

(See Rule-4)

To
..........
..........
..........

Sir,

The report about an accident which occurred on
...........at........(here enter details oI premises) and which
resulted in death / disablement oI the workman is Iurnished as given below:-

1. (a) Name oI the Workman,

(b) Sex, Age and monthly wage,

( c ) Nature oI employment.

( d ) Name oI the employer.

( e ) Full postal address oI the workman / dependants (local and permanent both)

(I) Full postal address oI the Iactory / establishment where its registered oIIice is
located.

2. The circumstances leading to death / disablement oI the workman:-
(a) Time oI the accident.
(b) Place where the accident occurred.
(c) Manner in which deceased was/were employed at that time.
(d) Cause oI the accident.

3. The amount oI money deposited by the employer with the Commissioner under
Section 8.

4. (a) Details oI compensation paid, iI any.
(b) Particulars oI money invested Ior the beneIit oI dependents oI deceased workman.
109


5. Documents Iorwarded (in original) as under:-
(a) Death CertiIicate.
(b) Disablement certiIicate Irom the competent medical authority.
(c )Receipt Ior Deposit oI Compensation by the employer.
(d) Statement oI Disbursement.
(e) Receipt oI compensation Irom the workman / dependants.
(I) Memorandum oI Agreement, iI any.



Dated: Commissioner.















110

FORM -EE

|See Rule 11|

REPORT OF FATAL ACCIDENTS

To

Sir,

I have the honour to submit the Iollowing report oI an accident which
occurred on (date), at (here enter details

oI premises) and which resulted in the death oI the workman / workmen oI
whom particulars are given in the statement annexed.

2. The circumstances attending the death oI the workman / workmen were
as under:-

(a) Time oI the accident:
(b) Place where the accident occurred:
(c) Manner in which deceased was / were employed at the time:
(d) Cause oI the accident:
(e) Any other relevant particulars:

I have, etc.,

Signature and designation oI
person making the report

Statement

Name Sex Age
Nature oI
employment
Full Postal Address





111
THE WORKMEN`S COMPENSATION
RULES, 1924



claim, and whereas the said ..... On notice served has claimed that you
.......... stand to him in the relation oI a contractor Irom whom the
applicant ...... could have recovered compensation you are hereby inIormed
that you may appear beIore me on ....... And contest the claim Ior
compensation made by the said applicant or the claim Ior indemnity made by the
opposite party...... In deIault oI your appearance you will be deemed to
admit the validity oI any award made against the opposite party and your liability to
indemniIy the opposite party Ior any compensation recovered Irom him.


Dated 20 Commissioner










112

FORM - K

(See Rule 48 )
MEMORANDUM OF AGREEMENT

It is hereby submitted that on the day oI 20
Personal injury was caused to residing at by
accident arising out oI and in the course oI employment in .

The said injury has resulted in temporary disablement to the said workman
whereby it is estimated that he will be prevented Irom earning more than his previous /
any wage Ior a period oI .......months. The said workman, has been in
receipt oI halI-monthly payments which have continued Irom the day oI
......... 20 , until the ......day oI ......20 amounting to Rs.
........in all. The said workman`s monthly wages are estimated at Rs.
. The workman is over the age oI 15 years / will reach the age oI 15 years on
.......

It is Iurther submitted that .........the employer oI the said workman
has agreed to pay, and the said workman has agreed to accept the sum oI
Rs....... in Iull settlement oI all and every claim under the Workmen`s
Compensation Act, 1923, in respect oI all disablements oI a temporary nature arising
out oI the said accident, whether now or hereaIter to become maniIest. It is thereIore
requested that this memorandum be duly recorded.


Dated Signature of emplover


Witness Signature of workman
Witness

113