Application for Compensation

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Full Text of the Document

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....ed 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 to Rs. ___ The applicant is over/under the age of 15 years (4 ) (a) Notice of the accident was served on ....