Notice in Form H containing the abstract from the Act shall be displayed by the employer in [the official language of the State and the language understood by a majority of the workers] at conspicuous place in his establishment and shall be maintained in clean and legible condition; and -------------- FORM A [See Rule 6(1)] Deposit of Compensation for Fatal Accident [Section 8(1) of the Workmen’s Compensation Act, 1923]
1. Compensation amounting to Rs. ___________ is hereby presented for deposit in respect of injuries resulting in the death of the workman, whose particulars are given below, which occurred on __________.
Name ____________________ Father’s Name (Husband’s name in case of married woman and widow)______________ Caste________________ Local address __________________________ Permanent address ______________________ His/her monthly wages are estimated at Rs. _______________ He/She was over/under the age of 15 years at the time of his/her death ________________
2. The said workman had prior to the date of his/her death received the following payments, namely, Rs.______________ on ___________Rs. ______________ on _______________ Rs.______________ on ___________Rs. ______________ on _______________ Rs.______________ on ___________Rs. ______________ on _______________ Rs.______________ on ___________Rs. ______________ on _______________ Amounting to all to Rs. __________________.
3. An advance of Rs. ______________ has been made on account of compensation to __________ being his/her dependent.
4. I do not desire to be made a party to the proceedings for distribution of the aforesaid compensation.
Dated________19. -------------- (Employer) FORM AA [See Rule 6(1)] Deposit of Compensation for Non-Fatal Accident to a Woman or person under Legal Disability.
[Section 8(1) of the Workmen’s compensation Act, 1923]
1. Compensation amounting to Rs. ______________ is hereby presented for deposit in respect of injuries _______________ sustained by residing at _______________ on __________ loss of ________________ temporary disablement. His/her monthly wages are estimated at Rs. ____________. He/She was over/under the age of 15 years at the time of the accident.
2. The said injured workman has prior to the date of the deposit received the following half-monthly payments, namely:
Rs.______________ on ___________Rs. ______________ on _______________ Rs.______________ on ___________Rs. ______________ on _______________ Rs.______________ on ___________Rs. ______________ on _______________ Dated ___________ ---------------- Employer FROM B [See Rule 6] Receipt of compensation [Deposited under Section 8(1) of the Workmen’s Compensation Act, 1923] Book No. Receipt No. Register No.
Depositor Deceased or injured workman Date of deposit _______19 Sum deposited, Rs.
----------------- Commissioner FORM O [See Rule 6] Statement of Disbursements Section 8(4) of the Workmen’s Compensation Act, 1923] Serial No.
Depositor Date Rs.
Amount deposited.
1. An employee desiring to be made a party to the proceedings should strike out the words ‘do not’.
Amount deducted and repaid to the employer under the proviso to Section 8(1).
Funeral expenses paid Compensation paid to the following dependants:
Name Relationship Dated 19 Total Commissioner FORM D [See Rule 9] Deposit of Compensation for Non-fatal Accidents, other than to a woman or person under Legal Disability [Section 8(2) of the Workmen’s Compensation Act, 1923] Compensating amounting to Rs. _______________ is hereby presented for deposit in respect of permanent/temporary injuries sustained by residing at _______________, which Occurred ____________ 19 _______.
Dated___________19_________ Employer FORM E [See Rule 9] Receipt of Compensation [Deposited under Section 8(2) of the Workmen’s Compensation Act, 1923] Book No. _________ Receipt No. ___________ Register No. ___________ Depositor In favour of Date of deposit Sum deposited Rs.
Commissioner FORM EE [See Rule 11] Report of Fatal Accidents -------------------- Sir,
1. I have the honour to submit the following report of an accident which occurred in (date), at (here enter details of premises) and which resulted in the death of the workman/workmen of whom particulars are given in the statement annexed.
2. The circumstances relating to the death of the workman/workmen were as under: -
(a) Time of accident.
(b) Place where the accident occurred.
(c) Manner in which deceased was/were employed at the time.
(d) Cause of the accident.
(e) Any other relevant particulars.
I have etc.
(Signature and designation of person making the report) Statement Name Sex Age Name of Full postal address Employment FORM F [See Rule 20] Application for Compensation by workman To the Commissioner for Workmen’s Compensation.
Applicant residing at Versus Opposite Party residing at It is hereby submitted that: -
(1) The applicant, a workman employed by a (contractor with) the opposite party on the date of 19 received personal injury by accident arising out of 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 amount of Rs.__________ The applicant is over/under the age of 15 years.
(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 applicant is accordingly entitled to receive: --
(a) half monthly payment of Rs. ___________From 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 question 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 applicants employment;
(c) Whether the a amount of compensation claimed is due, or any part of that amount;
(d) Whether the opposite party is liable to pay such compensation as is due;
(e) etc., (as required) Date_______________19 .
Applicant FORM G [See Rule 20] Application for order to Deposit Compensation To The Commissioner for Workmen’s Compensation residing at Applicant Versus Residing at Opposite Party It is hereby 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 an in the course of employment resulting in his death on the day of __________19____________ The cause of 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 amount 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 of 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.
FORM H [See Rule 20] Application for Commutation (Under Section 7 of the Workmen’s Compensation Act, 1923) To The Commissioner for Workmen’s Compensation.
residing at Applicant Versus residing at Opposite Party It is hereby submitted that –
(1) The applicant/opposite party has been in receipt of half monthly payment from ______ to _______ in respect of temporary disablement by accident arising out of and in the course of his employment.
(2) The application is desirous that the right to receive half-monthly payments should be redeemed.
(3) (a) The opposite party is unwilling to agree to the redemption of the right to receive half-monthly payments.
(b) The parties have been unable to agree regarding the sum for which the right to receive half-monthly payment should be redeemed.
You are therefore requested to pass order—
(a) directing that the right to receive half-monthly payments should be redeemed.
(b) Fixing a sum for the redemption of the right to receive half-monthly payments.
Dated _______1 . Applicant FORM J [See Rule 39] Notice Whereas a claim for compensation has been made by applicant, against _____________ and the said has claimed that you are liable under Section 12 (2) of the Workmen’s Compensation Act, 1923, to indemnify him against any compensation which he may be liable to pay in respect of the aforesaid claim, you are hereby informed that you may appear before me on _____________ and contest the claim for compensation made by the said applicant or the claims for indemnity made by the opposite party. In default of your appearance you will be deemed to admit the validity of any award made against the opposite party and your liability to indemnify the opposite party for the compensation recovered from him.
Dated _______ 19_______ . Commissioner FORM JJ [See Rule 39] Notice Whereas a claim for compensation has been made by __________ applicant against __________ and the said _________ has claimed that _________________________ is liable under Section 12 (2) of the workmen’s Compensation Act, 1923, to indemnify him against any compensation which he may be liable to pay in respect of the aforesaid claim, and whereas the said _____________________ on notice served has claimed that you ______________________ stand to him in the relation of a contractor from whom the applicant could have recovered compensation you are hereby informed that you may appear before me on ___________ and contest the claim for compensation made by the said applicant or the claim for indemnity made by the opposite party ________. In default of your appearance you will be deemed to admit the validity of any award made against the opposite party ________ and your liability to indemnify the opposite party for any compensation recovered from him.
Dated _______ 19_______ . Commissioner FORM K [See Rule 48] Memorandum of agreement It is hereby submitted on the day of _________19 _________ personal injury was caused to _________ resident at ________ by accident arising out of and in the course of employment in ________. The said injury has resulted in temporary disablement to the said workman whereby it is estimated that he will be prevented from earning more than of previous/any wages for a period of __________ months. The said workman has been in receipt of half-monthly payments, which have continued from the ___________ day________ of 19_____ until the continued from the day ________ of 19________ until the _________ day of ________19____ amounting to Rs. _______ in all. The said Workman’s monthly wages are estimated at Rs. ________. The workman is over the age of 15 years will reach the age of 15 years on __________.
It is further submitted that the employer of the said workman has agreed to pay, and the said workman has agreed to accept, the sum of Rs. _______ in settlement of all and every claim under the Workmen’s Compensation Act, 1923, in respect of all disablement of a temporary nature arising out of the said accident, whether now or hereafter to became manifest. It is therefore requested that this memorandum be duly recorded.
Dated______19 Signature of employer Witness Signature or workman Note. -- An application to register an agreement can be presented under the signature of one party: provided that the other party has agreed to the terms. But both signatures should be appended, whenever possible.
Receipt (to be filed in when the money has actually been paid).
In accordance with the above agreement, I have this day received the sum of Rs._______.
Dated_______19 . Workman The money has been paid and this receipt is signed in my presence.
Witness Note. -- This form may be varied to suit special cases, e.g., injury by occupational disease, agreement when workman is under legal disability, etc.
FORM L [See Rule 48] Memorandum of Agreement It is hereby submitted that on the _____ day of ______ 19 _______ personal injury was caused to ________ residing at by accident arising out of and in the course of his employment in ________ The said injury has resulted in permanent disablement to the said workman of the following nature, namely: -- The said workman’s monthly wages are estimated at Rs. ____________ The workman is over the age of 15 years will reach the age of 15 years on ______________.
The said workman has, prior to the date of the agreement, received the following payments, namely: -- Rs.______________ on ___________Rs. ______________ on _______________ Rs.______________ on ___________Rs. ______________ on _______________ Rs.______________ on ___________Rs. ______________ on _______________ It is further submitted that the employer of the said workman has agreed to pay, and the said workman has agreed to accept, the sum of Rs. _______ in full settlement of all and every claim under the workman’s Compensation Act, 123 in receipt of the disablement stated above and all disablement now manifest. It is therefore requested that this memorandum be duly recorded.
Dated _______ 19 . Signature of employer Witness Witness Signature or workman Note. -- Application to register an agreement can be presented under signature of one party: provided that the other party has agreed to the terms. But both signatures should be appended, whenever possible.
Receipt (to be filled in when the money has actually been paid) In accordance with the above agreement, I have this day received the sum of Rs._______.
Dated__________19 . Workman The money has been paid and this receipt signed in my presence.
Witness Note. -- This form may be varied to suit special cases, e.g. injury by occupational disease, agreement when workman is under legal disability, etc.
FORM M [See Rule 48] Memorandum of Agreement It is hereby submitted that on the _______ day of _______ 19________ personal injury was caused to __________ residing at _________ by accident arising out of said in the course of employment in ________________. The said injury has resulted in temporary disablement to the said workman, who is at present in receipt of wages amounting to Rs.
_________ per month/no wages.
The said workman’s monthly wages prior to the accident are estimated at Rs. _______.
The workman is subject to a legal disability by reason of.
It is further submitted that the employer of the workman has agreed to pay and on behalf of the said workman has agreed to accept half-monthly payments at the rate of Rs. _____ for the period of the said temporary disablement. This agreement is subject to the condition that the amount of the half-monthly payments may be varied in accordance with provisions of the said Act on account of an alteration in the earnings of the said workman during disablement. It is further stipulated that all rights of commutation under Section 7 of the said Act are unaffected by this agreement it is therefore requested that this memorandum be duly recorded.
Dated _________ 19 . Signature of employer Witness Signature of workman Witness Note. -- An application to register and agreement can be presented under the signature of one party : provided that the other party has agreed to the terms. But both signatures should be appended, whenever possible.
Receipt (to be filled in when the money has actually been paid).
In accordance with the above agreement, I have this day received the sum of Rs. ______.
Workman Dated_________ 19 .
The money has been paid and this receipt signed in my presence.
Note. -- This form may be varied to suit special cases, e.g., injury by occupational disease, etc.
FORM N [See Rule 9] Whereas an agreement to pay compensation is said to have been reached between _______ and __________ and whereas has/have applied for registration of the agreement under Section 28 of the Workmen’s Compensation Act, 1923, notice is hereby given that said agreement will be taken into consideration on ________ 19 _________ and that any objections to the registration of the said agreement should be made on that date. In the absence of valid objections it is my intention to proceed to the registration of the agreement.
Dated_________ 19______.
Commissioner FORM O [See Rules 49 and 50] Take notice that registration of the agreement to pay compensation said to have been reached between you _______ on the 19_________ has been refused for the following reasons namely: -- Commissioner FORM P [See Rule 50] Whereas an agreement to pay compensation is said to have been reached between _______ and _______ and whereas __________ has/have applied for registration of the agreement under Section 28 of the Workman’s Compensation Act, 1923 and whereas it appears to me that the said agreement ought not to be registered for the following reasons namely:
An opportunity will be afforded to you of showing cause on ________ 19 ________ why the said agreement should be registered. If no adequate cause is shown on that date, registration of the agreement will be refused.
Dated_______ 19________.
Commissioner FORM Q [See Rule 50] Whereas an agreement to pay compensation is said to have been reached between _________ and _______ and whereas __________ has/have applied for registration of the agreement under Section 28 of the Workman’s Compensation Act, 1923, and whereas it appears to me that the said agreement ought not to be registered for the following reasons, namely an opportunity will be afforded to the said _______ of showing cause on _________ 19________ why the said agreement should be registered. Any representation, which you have to make with regard to the said agreement, should be made on that date. If adequate cause in them shown, the agreement may be registered.
Dated_______ 19______ Commissioner FORM R [See Rule 52] Register of Agreement for year 19_______.
S.No. Date of Date of Employer Workman Initial Reference to agreement registration of comm.- orders rectifyi- -issioner -ng the register 1 2 3 4 5 6 7 Workmen’s Compensation Returns (Government of India, Department of Industries and Labour Notification No. L- 1189, dated the 28th. March, 1935) In exercise of the powers conferred by Section 16 of the Workmen’s Compensation Act, 1923 (VIII of 1923), and in suppression of the Notification of the Government of India in the Department of Industries and Labour, No. L-1189 dated the 26th. June, 1924, the Governor General in Council is pleased to direct that an annual return in the form set forth in the Schedule hereto annexed shall be furnished by every person employing workmen who are: -- (A) employed in a place, which is factory within the meaning of clause (j) of Section 2 of the Factories Act, 134;
(B) employed within the meaning of clause (d) of Section 3 of the Indian Mines Act, 1923 in any mine, which is subject to the operation of that Act;
(C) employed as railway servants otherwise than in a factory or mine;
(D) employed otherwise than in a clerical capacity in a factory or mine in connection with the operation or maintenance of a Tramway as defined in Section 3 of the Indian Tramways Act, 186;
(E) employed in any of the following categories but not falling under any of the foregoing heads (A), (B), (C) and (D)—
(i) otherwise than in a clerical capacity in the service of any Port Trust of Port Commission within the limits of any port subject to the Indian Ports Act, 1908;
(ii) in the manufacture or handling of explosives in any premises wherein, or within the precincts thereof, on any one day of the preceding twelve months, ten or more persons have been so employed;
(iii) in the service of any fire brigade;
(iv) otherwise than in a clerical capacity in connection with operation for winning natural petroleum or natural gas;
(v) otherwise than in a clerical capacity on any estate which is maintained for the purpose of growing cinchona, coffee, rubber, or tea, and on which on any one day in the preceding twelve-months twenty-five or more persons have been so employed;
(vi) otherwise than in a clerical capacity in the generating, transforming or supplying of electrical energy;
(vii) in producing cinematograph pictures.
2. The return, which shall relate to a calendar year shall be furnished on or before the 1st.
February following the year to which the return relates and the first return shall relate to the year, 1935.
3. The return shall be signed (a) by the employers, or where there is more than one employer by any employer, (b) by any person directly responsible to the employer or employers for the management of the establishment to which it relates.