(1) This Scheme may be called the Personal Injuries (Compensation Insurance) Scheme, 1972.

(2) It shall come into force on the 3rd December, 1971.

In this Scheme, unless the context otherwise requires,

(a) Act means the Personal Injuries (Compensation Insurance) Act, 1963 (37 of 1963);

(b) Annexure means the annexure appended to the Scheme;

(c) advance premium means the advance payments against the total premium to be paid by an employer as required in clause 6;

(d) Claims Officer means the officer appointed as Claims Officer for the purposes of the Personal Injuries (Emergency Provisions) Scheme, 1971 made under the Personal Injuries (Emergency Provisions) Act, 1962 (59 of 1962);

(e) clause means a clause of this Scheme;

(f) Commissioner means a Commissioner for Workmen's Compensation appointed under Section 20 of the Workmen's Compensation Act, 1923 (8 of 1923);

(g) compensation means compensation payable under Sections 4 and 7 of the Act;

(h) dependant has the meaning assigned to it in the Workmen's Compensation Act, 1923 (8 of 1923);

(i) eligible member of a family means:

(i) a widow lawfully married,

(ii) a legitimate son,

(iii) a legitimate daughter,

(iv) father,

(v) mother, and

(vi) any other dependant to whom the Claims Officer thinks that compensation should be paid;

(j) Form means a form appended to this Scheme;

(k) Government Agent means any person employed under Section 11 to act as the agent of the Central Government for any of the purposes of the Act;

(l) Head of account means head of account specified in sub-clause (2) of clause 4;

(m) period of emergency means the period beginning with the third day of December, 1971, and ending with such date as the Central Government may, by notification in the Official Gazette, declare to be the date on which the emergency shall come to an end;

(n) policy means a policy of insurance issued under this Scheme;

(o) qualifying injury means a personal injury sustained by a gainfully occupied person in respect of which compensation is payable under Section 4 of the Act;

(p) quarter means a period of three months, commencing on the first day of April, July, October or January;

(q) section means a section of the Act;

(r) all other words and expressions used in the Scheme but not defied herein shall have the meanings respectively assigned to them in the Act.

(1) Every employer shall take out in the manner indicated in this Scheme, a policy of insurance as laid down in Section 9 and pay such advance premiums as may be notified under clause 8 and such final premium as may after the expiry of the period of the emergency be notified under clause 6.

(2) An employer who has fulfilled such of his obligations under sub-clause (1) as have fallen due shall be entitled to have any liability for the payment of compensation incurred by him under the Act discharged on his behalf by the Government out of the Fund.

(3) Where an employer has failed to fulfil such of his obligations under sub-clause (1) as have fallen due any compensation for the payment of which he is liable under the Act shall be paid out of the Fund, but any amount so paid shall be capable of being recouped from the employer in accordance with the procedure provided in that behalf in the Act.

(1) Every employer required to take out a policy of insurance under Section 9 shall apply to the government agent or to such officer as may be authorised by the government agent in this behalf, for insurance.

(2) Every such application shall be made in duplicate in Form A and shall be accompanied by a treasury challan evidencing payment of the requisite advance premium into a Government Treasury under the head LII Miscellaneous Receipts under Personal Injuries (Compensation Insurance) Scheme, 1972.

(3) If no challan accompanies an application, or if the challan is not in order, the application shall be returned to the applicant for re-submission along with the required challan.

(4) If the chalan accompanying an application is in order but the application for insurance is not received in Form A, the challan may be retained by the government agent and the application returned to the applicant for re-submission after being correctly made out.

(5) If the challan accompanying an application is for an amount which falls short of the premium due, the application, if otherwise in order, may be kept in suspense, pending the receipt of a challan for the balance of the amount by which the original challan falls short.

(6) The government agent shall give a receipt in Form B for the application received from the employer.

If the application has been correctly made out in Form A and is accompanied by a treasury challan evidencing payment of the full advance premium required under clause 8 into a Government Treasury under the head of account the government agent shall issue a policy of insurance as soon as possible, after the receipt of the application.

(1) The total premium due on a policy of insurance shall be determined by the Central Government by a notification in the Official Gazette within nine months after the termination of the period of emergency.

(2) The premium shall be expressed as a percentage of the wages bill of the employer or as the equivalent of all advance payments of premium already made by him.

(3)(a) This premium , less such advance premiums as may have been recovered, will be payable by employers in such instalments as may be fixed by the Central Government.

(b) Each such instalment shall be paid into a Government Treasury under the head of account through a challan and the challan evidencing such payment shall be forwarded to the government agent within 30 days of the date fixed for payment by a notification in the Official Gazette.

(4) If the advance premium already recovered exceeds the total premium, then the excess shall be refunded by the Central Government to the employer.

For the purpose of calculating the total premium due from any employer on a policy of insurance, the total wages bill of that employer for the four complete quarters preceding the date of termination of the period of emergency shall be the wages bill on which percentages will be charged:

Provided that in respect of an employer who has gone out of business before that date, the period shall be the four complete quarters preceding the date on which he goes out of business.

(1) The amount of the advance premium payable 2[for the quarter ending 31st December, 1971], against the total premium to be determined under clause 6 shall be at the rate of three paise per one hundred rupees of the relevant wages bill.

(2) The amount of advance premiums payable during subsequent quarters which shall be expressed as a percentage of the relevant wages bill of each employer shall be payable at such rates as may be notified from time to time by the Central Government in the Official Gazette in this behalf.

(3) Advance premiums shall not be required to be paid more frequently than once in a quarter.

(4) The relevant wages bill for an advance premium shall be the wages bill for the quarter preceding the one in which the advance premium is required to be paid.

(5) If at any time the Central Government is of opinion that the balance in the fund is sufficient to meet the probable liabilities of the fund as foreseen at that time, the Central Government may waive or postpone the payment of advance of premium during the current or any future quarter.

(6) All advance premiums shall be paid by the employer into a Government treasury under the head of account and the treasury challan evidencing payment of the advance payments shall be forwarded by the employer to the government agent, to whom the application under Clause 4 is required to be made within such time as may be specified by the Central Government in the Official Gazette in this behalf.

(7) The final premium and the advance premiums shall be rounded off to the nearest rupee.

3[(7-A) The minimum final premium and the minimum advance premium payable by an employer shall be rupee one.]

(8) The government agent or his officer shall give a receipt in Form C for each advance premium after the first paid by the employer.

The value in lump sum of the pensions and allowances payable under the Personal Injuries (Emergency Provisions) Act, 1962, and specified in Column 1 of the Table below shall be the corresponding amount indicated in Column 2 thereof:

TABLE

(1) Subject to the provisions of Section 7 read with Clause 9 and sub-clause (2) of this clause, the amount of compensation payable shall be as follows:

(a) Where death results from the injury and the deceased person has been in receipt of monthly wages falling within limits shown in the first column of the Annexure the amount shown against such limits in the corresponding entries in the second column thereof;

(b) Where permanent total disablement results from the injury and the injured person has been in receipt of monthly wages falling within the limits shown in the first column of the Annexure the amount shown against such limits in the corresponding entries in the third column thereof;

(c) Where permanent partial disablement results from the injury:

(i) in the case of an injury specified in the Schedule to the Act such percentage of the compensation which would have been payable in the case of permanent total disablement as is specified therein as being the percentage of the loss of earning capacity caused by that injury, and

(ii) in the case of an injury not specified in the Schedule to the Act, such percentage of the compensation payable in the case of permanent total disablement as is proportionate to the loss of earning capacity permanently caused by the injury;

(d) Where temporary disablement, whether total or partial, results from the injury and the injured person has been in receipt of monthly wages falling within limits shown in the first column of the Annexure, a half-monthly payment of the sum shown against such limits in the corresponding entries in the fourth column thereof payable on the sixteenth day:

(i) from the date of the disablement, where such disablement lasts for a period of twenty-eight days or more; or

(ii) after the expiry of a waiting period of three days from the date of the disablement where such disablement lasts for a period of less than twenty-eight days,

and thereafter half-monthly for so long as he receives any payment under the Scheme made under the Personal Injuries (Emergency Provisions) Act, 1962.

(2) Notwithstanding anything contained in sub-clause (1), the amount of compensation payable to a government servant under this Scheme shall in accordance with Section 6 of the Act be equal to the amount of compensation that would have been payable under sub-clause (1) plus the appropriate lump sum value of the payments under the Personal Injuries (Emergency Provisions) Act, 1962, specified in Clause 9 reduced by the lump sum value of the extraordinary pension, gratuity, compassionate payment or damages repayable to him under the rules regulating the conditions of his service.

Compensation in respect of a qualifying injury sustained by a workman shall be admissible only if the injury was sustained at any time:

(a) on a day on which he was on duty as such workman, or

(b) on a day on which he would have been on duty but for that day being a recognised holiday or day of rest or for his being casually absent from duty on account of illness, injury or other similar cause, or for any other reason which in the opinion of the Claims Officer was good and sufficient.

(1) The employer of a workman sustaining a qualifying injury may grant to the workman himself or in the year of his death to any person to whom compensation would be payable under Clause 18 an advance on account of compensation not exceeding two hundred rupees.

(2) Upon acceptance of an advance payment in accordance with sub-clause (1) the recipient thereof shall give to the employer a receipt in duplicate in Form D.

(3)(a) An employer who wishes to claim a refund of the advance payment made by him to a workman or an eligible member of his family under sub-clause (1) shall, within two weeks of making such advance, make an application in Form E therefor to the Claims Officer having jurisdiction in the area where the injury was sustained.

(b) The application referred to in sub-clause (a) shall be accompanied by a copy of the receipt given by the workman or an eligible member of his family in Form D.

(4) So much of the amount paid under sub-clause (1) as does not exceed the compensation payable to the same person under an award made under this Scheme shall be repayable to the employer from the Fund.

(5) When making an award under this Scheme for an injury in respect of which the employer of the injured person has made an advance payment to the workman or an eligible member of his family under sub-clause (1), the Claims Officer shall, on receipt of an application under sub-clause (3), make an order in Form F requiring the repayment of the advance payment to the employer and shall reduce the award by the amount of such order.

(1) An application for compensation under this Scheme shall be made to the Claims Officer of the area where the injury was sustained within eight months after the date of sustaining the qualifying injury by any of the following persons in the manner laid down in Clause 14, namely:

(i) the workman, or

(ii) in case of workman's death, an eligible member of the workman's family.

(2) The Claims Officer may accept an application from the employer of the workman on behalf of the workman or his family, if such officer is satisfied that it is in the interest of the workman so to do or in the event of his death, of an eligible member of the workman's family.

(3) Where the Claims Officer is satisfied that a person by whom an application should be made is for sufficient reason incapable of making the same, the Claims Officer may entertain an application made on such person's behalf by any other person.

(4) (a) An application made after the period of eight months of the date of the qualifying injury shall not be considered,

(b) but the Claims Officer may, in his discretion, if he is satisfied that the delay has been due to valid reasons, admit the application.

(I) An application for compensation by the workman sustaining the qualifying injury shall be made in Form G to the Claims Officer through the person in charge of the hospital or dispensary where he last received or is receiving treatment, or if he has not been treated in any hospital or dispensary, through the Medical Officer of Government or a registered medical practitioner, if any, who last treated him for the injury, and shall be counter-signed by such person, officer or practitioner.

(2) An application for compensation made by an eligible member of the workman's family on behalf of the workman sustaining the qualifying injury shall be in Form H.

(3) An application in respect of compensation made under sub-clause (3) of Clause 13 or by an employer under sub-clause (2) of Clause 13 shall be in Form I.

(1) On receipt of an application for compensation in Form G, H, or I the Claims Officer shall require the employer to submit a return in duplicate in Form J within such time as may be prescribed by the Claims Officer.

(2) An advance payment made under Clause 12 shall not be refundable if not recorded in Form J.

(3) An advance payment made after submission of Form J by the employer shall not be refundable.

(1) The Claims Officer shall forward the duplicate copy of the return in Form J received under sub-clause (1) of Clause 15, to the Government agent.

(2) The Government agent shall verify the correctness of the particulars given in the return by the employer regarding the policy taken out by him and if it is found that the policy quoted is not valid, the Government agent shall inform the Central Government accordingly and also at the same time forward the connected papers to that Government.

(1)(a) When an application for compensation under this Scheme is received, the Claims Officer shall, after considering the reports and certificates pertaining to the case and after obtaining such other evidence, if any, as he considers necessary, and in addition to the award under the Scheme made under the Personal Injuries (Emergency Provisions) Act, 1962 (59 of 1962), make another award, or awards in Form K when there are several eligible members, under the provisions of this Scheme for the payment of compensation under the provisions of the Act.

(b) The Central Government may make a similar award in respect of cases in which relief has been granted under Clause 46 of the Scheme made under the Personal Injuries (Emergency Provisions) Act, 1962 (59 of 1962).

(c)(i) A signed and sealed copy of the award shall be given to the person in whose favour the award is made or to his authorised agent;

(ii) a true copy shall be sent to the employer of the workman concerned together with attested specimens of thumb and finger-impressions of the payee and his signature, if literate;

(iii) a true copy shall be sent to the Post Office where the payment is to be made, together with attested specimens of the thumb and finger-impressions of the payee and his signature, if literate;

(iv) and another true copy shall be sent to the audit officer specified for this purpose by the Director-General of Posts and Telegraphs.

(2) If an application for compensation is rejected, the reasons for such rejection shall be recorded in the Order passed and a copy of the Order shall be given free of cost to the applicant.

The amount of compensation in respect of death shall be paid and distributed by the Claims Officer in like manner as compensation in respect of a workman whose injury has resulted in death is paid and distributed by a Commissioner under Section 8 of the Workmen's Compensation Act, 1923, except that the payment shall be made through an award in Form K, under Clause 17.

(1) When compensation admissible under the Act to any person is less than or equal to, five hundred rupees, it shall be paid as lump sum.

(2) When the compensation admissible under the Act to a person exceeds five hundred rupees, a part of the admissible amount up to the extent of five hundred rupees shall be paid as a lump sum and the balance shall be paid in monthly or quarterly instalments at such rate as may be prescribed by the authority making the award under Clause 17 or the authority issuing directions under clause 21:

Provided that the number of instalments shall not exceed 60 in the case of monthly instalments and 20 in the case of quarterly instalments.

(1) Compensation under this Scheme shall be payable at all head and sub-post offices and such branch post-offices in India as may be authorised in this behalf by the head of the circle or in the case of Nagaland by the Deputy Commissioner or the Sub-Divisional Officer.

(2) All such amounts shall be drawn within three months of the date when they are due.

(3) All such payments shall from time to time be endorsed on the award by the Postmaster concerned.

The Claims Officer may withhold, cancel, review or alter an award under this Scheme under the same conditions and circumstances as are specified for the withholding, cancellation, review or alteration, as the case may be, of an award made under the Personal Injuries (Emergency Provisions) Scheme, 1971, in respect of the same workman and in respect of the same injury:

Provided that no such withholding, cancellation, review or alteration shall be made to recover any amounts already paid under this Scheme:

Provided further that the amount of compensation shall not be increased beyond the limits specified in, or for the purposes of, this Scheme.

An appeal against any order made by the Claims Officer under this Scheme shall lie to such authority as may be specified in this behalf by the Central or the State Government.

An employer desiring to be exempted from the provisions of the Act under Section 21 shall make an application to the Central Government in Form L.

The liabilities under this Scheme of the contractor and the principal as defined in Section 10, shall be as follows:

The Contractor. (a) The contractor shall be under an obligation in like manner as if he were any other employer for insuring the workman working under him.

(b) The contractor shall be responsible for informing the principal of the number and date of the policy taken out by him from the government agent.

The principal. The principal shall be responsible for bringing to the notice of the government agent the existence of any contractors working under him, but the principal will not be responsible for the accuracy of figures included in the application made by the contractor.

Any person who contravenes any requirement of the scheme shall be punishable for every such contravention with fine which may extend to two thousand rupees.

[See clause 10]

Note: Compensation for permanent partial disablement is calculated as follows: The extent of permanent partial disablement is expressed in percentages of loss of earning capacity. These percentages are percentages of the compensation which would be payable in the case of permanent total disablement.

[See Clause 4]

Important: Before completing this application form read the instructions overleaf.

GOVERNMENT OF INDIA

PERSONAL INJURIES (COMPENSATION INSURANCE) ACT, 1963

1. Employer's Name ..

2. Business Address ..

3. Date on which the employer became liable to take out the insurance.

4. Description of trade or business and Schedule of employees.

*For calculation of the wages and allowances each person's monthly earnings above Rs. 500 should be ignored.

5. Advance against premium calculated to the nearest Rupee at . per cent equal to Rs

6. Have you employed any contractor or contractors in the preceding quarter(s)? If so give:

(For definition of Contractor see para 10 overleaf)

To

(Here insert the name of the government agent)

(To be completed when application for insurance is first made)

I/We warrant that the above Statements and particulars are true and I/We request you to effect insurance on my/our behalf with the Government of India in terms of the prescribed standard policy which I/We agree to accept.

I/We further agree that this application and all the declarations that will be made by me/us hereafter from time to time in relation to the policy to be issued to me/us against this application shall be the basis of the contract between the President of India and myself/ourselves.

I/We enclose challan dated .. for Rs . paid into

(*Strike out whichever is inapplicable)

(To be completed when submitting a declaration of wages subsequent to original application)

I/We warrant that the above statements and particulars are true and I/We enclose challan dated for Rs .. deposited in the

against premium payable during the quarter ending .

The number of my/our policy is .

Signature of Employer

Dated ..

(*Strike out whichever is not applicable)

1. Liability. The above Act imposes on employers of persons engaged in essential services, in factories, mines, major ports, plantations and other employments to be specified, an obligation to pay compensation in respect of personal injury to their employees amounting to the difference between the amount which would have been payable under the Workmen's Compensation Act, 1923, and the amount paid by Government under the Personal Injuries (Emergency Provisions) Scheme, 1962, if the personal injury had given a right to compensation thereunder. The Act extends to the whole of India.

2. Compulsory Insurance. All employers to whom the Act applies must insure their liability with the Central Government and the Act prescribes heavy penalties for failure to ensure or failure to pay any advance against premium due or failure to pay compensation due under the Act.

3. Employers to whom the Act applies. The Act applies to all employers throughout India of persons employed in:

(a) any employment or class of employments which is or has been declared to be an essential service under Rule 126-AA of the Defence of India Rules, 1962 or under Rule 119 of the Defence of India Rules, 1971;

(b) any factory as defined in clause (m) of Section 2 of the Factories Act, 1948;

(c) any mine within the meaning of the Mines Act, 1952;

(d) any major port as defined in the Indian Ports Act, 1908;

(e) any plantation as defined in clause (f) of Section (2) of the Plantations Labour Act, 1951;

(f) any employment specified in this behalf by the Central Government by notification in the Official Gazette.

Please indicate category or categories of employments in column 4 of the Form.

4. Employers not required to insure. The following classes of employers are not required to insure under the Act:

(a) The Central and State Government; [Section 9(3)];

(b) employer whose total wages bill for any quarter after the commencement of the Act has never exceeded fifteen hundred rupees; [Section 9(1)];

(c) short-term contractors, i.e., where the loaning or letting on hire of the services of the workmen, or the execution of work, is for a term of less than one month; [Section 10(2)];

(d) employers exempted under Section 21 of the Act.

5. Employees included. All direct employees, including Managers, Supervisors, Assistants, etc., and all contractors' employees (see definition of Contractor ) are included in the Scheme. It should be noted that all employees in the employments referred to are covered and the application of the Act is not restricted to a specific class, e.g., workers defied in the Factories Act.

6. How to insure. The application Form should be completed and forwarded in duplicate to the government agent.

All applications must be accompanied by a treasury challan evidencing the payment of the requisite advance premium into the Treasury/Reserve Bank of India/State Bank of India, as the case may be, the advance premium being calculated to the nearest rupee.

7. Date by which policy to be taken. An application for taking out a policy of insurance shall be made:

(a) If the employer had been an employer for the complete quarter ending 31st December, 1971 then on or after the 10th June, 1972 and not later than 4[31st December], 1972.

(b) All other cases, within one month of the employer's having been an employer for one complete quarter.

8. Rate of premium. The total premium payable will be decided by Government after the termination of the emergency when the total liability has been ascertained. In the meantime, employers will be required to pay to Government periodic advance payments against this premium and the amount of advance premium payable during any quarter shall be such percentage of the wages bill of the previous quarter as may be notified by the Central Government from time to time.

The rate of the advance premium for the quarter ending 5[31st December, 1971], has been fixed at three paise per Rs. 100 of the wages bill in respect of the quarter ending 6[30th September, 1971].

9. Definition of Wages Bill . For the purpose of computing the wages bill on which is based the amount of premium, the total is taken only of the gross cash wages including overtime wages and allowances of all workmen excluding all that part of gross cash wages and allowance of individual employees which exceed Rs. 500 per month and bonus paid on profits.

It is the wages bill so computed that should be entered in the application form.

10. Definition of Contractor . Please see Section 10 of the Act. Unlike the provisions of the Workmen's Compensation Act, 1923, the contractor is liable in respect of workman whose services are temporarily lent or let on hire to another.

The liabilities of the Principal and Contractor under the Scheme are as follows:

The Contractor. (a) The contractor shall be under an obligation in like manner as if he were any other employer for insuring the workman working under him.

(b) The contractor shall be responsible for informing the principal of the policy number and date of insurance effected by him.

The Principal. The principal shall be responsible for bringing to the notice of the government agent the existence of any contractors working under him. The principal will not be responsible for the accuracy of figures included in the application made by the contractor.

11. Definition of Quarter . A quarter means a period of three months commencing on the 1st day of April, July, October and January.

For relevant quarter for which the wages are calculated and calculation of advance premium please see Clause 8.

[See Para 4(6)]

[See Para 8(8)]

Received from the Employer shown herein the challan mentioned above towards advance against premium under the Policy payable during the quarter ending

[See Para 12(2)]

To be submitted in duplicate

Received from of an advance payment of Rs (Rupees ) under clause 12 of the Personal Injuries (Compensation Insurance) Scheme, 1972, with reference to the injury sustained on .. at by of .

Ticket No. .

Department ..

Employee of

In consideration of the advance, I hereby enter into the undertaking that the amount of this advance may be deducted under the provisions of the Personal Injuries (Compensation Insurance) Scheme from out of any award made (either to me or to my relatives) *in respect of the aforesaid injury sustained by deceased/me.

Date .

Witness

of ..

Signature or thumb-impression of ..

Address

* Only when receipt is given by the injured person.

[See Para 12(3)(a)]

To the Claims Officer for . (area) I/We, the firm of Messrs .. do hereby declare that I/we have paid to .. whose age, description and other details are given below a sum of Rs . an aggregate sum of Rs . as an advance payment for the injury sustained by of .

Ticket No. .

Department ..

a workman in employment under me/our firm. The advance payment was made on .. and a duplicate copy of the receipt is attached hereto.

I/We the firm of Messrs . claim a refund of the amount stated above and request you to pass an order for the repayment of the said amount to me/us at . Post Office.

Name

Relation with deceased

in case of workman's death.

Father's name

AgeResidence

Profession

[See Para 12(5)]

Forwarded to the payee . (Name and address of Payee)

Copy forwarded to the Distt. Post Master/Post Office.

[See Para 14(1)]

Claimant's full name (in capitals)

Name of father (in the case of married woman, of husband)

Age

Date of birth

Profession

Residence

Nationality

Monthly rate of wages at the time the injury was sustained.

What amount of compensation is claimed and justification for the claim

Name of the employer and his full address

Ticket number, if any, and department in which employed

The amount of advance received from employer.

Place where injury was sustained

Date of Injury

Cause of injury, in detail

Details of injury

If taken to dispensary or hospital, which and when?

If discharged from dispensary or hospital, when?

If attended to at residence by a medical practitioner, details of place where treated and name of medical practitioner.

If any temporary allowance and/or pension is being or has been drawn by the injured person details thereof.

The compensation may be made payable at Post Office

I certify that I am not in receipt of any compensation under the Personal Injuries (Compensation Insurance) Scheme, 1965 or the Personal Injuries (Compensation Insurance) Scheme, 1972, other than that claimed above in respect of the personal injury sustained by me.

I certify that the information furnished above is true to the best of my knowledge and belief.

[See Para 14(2)]

*If necessary, this may be done on a sheet to be attached and signed.

Widow or widows, legitimate son(s), legitimate daughter(s), father, mother, state also if any has since died, or whether any female relative has since married or remarried.

Residence:

If staying elsewhere than

with applicant, state details.

In the case of daughter, whether married.

In the case of children, Guardian, if any, other than applicant

If any of the said relatives or the applicant

(i) draws any other pension and/or allowance from public funds, state details as to the source and amount.

(ii) holds any appointment under Government, state details and rate of emoluments.

Amount and particulars of the claim made:

The compensation may be made payable at Post Office

I certify that I am not in receipt of any compensation under the Personal Injuries (Compensation Insurance) Scheme, 1965, or the Personal Injuries (Compensation Insurance) Scheme, 1972, other than that claimed above in respect of the personal injury sustained by the deceased.

I certify that the information furnished in the statement is true to the best of my knowledge and belief.

[See Para 14(3)]

Name of applicant (if other than the employer) and full address.

Name of employer and full address.

Name(s) of person(s) on whose behalf application is made.

Name of workman sustaining qualifying injury.

Name of workman's father (in the case of married woman, of husband).

Ticket number, if any, and department in which employed.

Age of workman at the time of receiving injury.

Residence.

Place of qualifying injury.

Date and time of qualifying injury.

Whether the qualifying injury resulted in death or not?

If Workman received or is receiving any medical treatment, details thereof including place where received.

*If workman died in hospital or dispensary give details. If not, give any other proof of death, e.g., affidavits, or any certificates by a Gazetted Officer, Magistrate or Sub-Inspector of Police.

Amount of compensation claimed.

Amount of advance, if any, already paid to workman or his dependants.

Monthly rate of wages of the workman at the time the injury was sustained or death occurred.

Period during which the workman was employed.

Nature of employment.

Number and date of Policy taken by employer under clause 5 of the Personal Injuries (Compensation Insurance) Scheme, 1972.

I certify that to the best of my knowledge and belief no other application for compensation in respect of this injury has been made by any person and that I am acting on behalf of the

The compensation may be made payable at .. Post Office.

I also certify that the information furnished in the statement is true to the best of my knowledge and belief.

*To be filled up only in case of death of the workman.

To be filled up by the employer when the application is made by him.

[See Para 15]

If the workman is entitled to any compensation under Section 5 (extracted on reverse), give details:

Age of workman

Description of workman

Nature of injury

(To be printed on reverse)

SECTION 5 OF THE PERSONAL INJURIES (COMPENSATION INSURANCE) ACT, 1963

5. Where any person has a right apart from the provisions of this Act and of the Personal Injuries (Emergency Provisions) Act, 1962, to receive compensation (whether in the form of gratuity, pension, compassionate payment or otherwise) or damages from an employer in respect of a personal injury in respect of which compensation is payable under this Act, the right shall extend only to so much of such compensation or damages as exceeds the amount of compensation payable under this Act.

[See Para 17(1)]

IMPORTANT. In the case of government servants no award shall be made except in accordance with clause 10(2) of the Scheme, which reads as follows:

(2) Notwithstanding anything contained in sub-clause (1), the amount of compensation payable to a government servant under this Scheme shall in accordance with Section 6 of the Act be equal to the amount of compensation that would have been payable under sub-clause (1) plus the appropriate lump sum value of the payments under the Personal Injuries (Emergency Provisions) Act, 1962, specified in clause 9 of this Scheme, reduced by the lump sum value of the extraordinary pension, gratuity, compassionate payment or damages payable to him under the Rules regulating the conditions of his service.

Name of Claims Officer

sustaining qualifying injury

Name of person

killed

Name of father of such person

(in case of married woman, of husband)

Date and place of injury/death

Compensation in favour of (block capitals)

Name of father of such person if other than the person sustaining qualifying injury (in the case of married woman, of husband)

Description of such person

Amount of compensation

A lump sum of Rs .. and in addition a payment of Rs . per .. month/quarter

Guardian, if any

monthly

Period for which the payment is sanctioned with the date of commencement

quarterly

Payable at . Post Office

on the .. of each .

the amount

Being satisfied that the sum of Rs .. of an advance payment

unrepaid balance

made in accordance with sub-clause (1) of clause 12 of the Personal Injuries (Compensation Insurance) Scheme, 1972 by (Name and address) the employer of in respect of whose injury this award is made, is due to the said employer, I direct that the said sum be deducted from the sums payable under this award in the following manner:

Deduction from lump sum payment of Rs . and in addition

per month months.

deduction of Rs . for ..

quarter quarters.

Date and signature of Claims Officer.

Forwarded to the payee

(Name and address of Payee)

COURT'S SEAL

Copy forwarded to:

TABLE

(To be filled by the Postmaster or other authorised officer)

[See Para (23)]

Name of employer

Full address

Particulars of concern or concerns in respect of which exemption is sought.

Name of concern

*Number of workmen employed

Average monthly wages bill

Period for which exemption is sought

Reason for asking for exemption

Amount of compensation which the employer has undertaken to give to the employees

The name of the firm with which the liability has been insured

Number and date of policy

Period covered by the Insurance.

I declare that information given above is true.

*Only workmen to whom the Act would be applicable should be included.

1. Vide Notification No. S.O. 378(E), dt. 25-5-1972, published in the Gazette of India, Extra., Pt. II, S. 3(ii), dt. 25-5-1972, p. 1011.

2. Subs. by S.O. 500(E), dt. 22-7-1972.

3. Ins. by S.O. 500(E), dt. 22-7-1972.

4. Subs. for 31st October by S.O. 709(E), dt. 15-11-1972.

5. Subs. for 31st March, 1972 by S.O. 141(E), dt. 14-3-1973 (w.e.f. 3-12-1971).

6. Subs. for 31st December, 1971 by S.O. 141(E), dt. 14-3-1973 (w.e.f. 3-12-1971).