Employees' State Insurance (Central) Rules, 1950
FORM II: Application to Medical Appeal Tribunal
[Rule 20A (2)]
To
Chairman of Medical Appeal Tribunal
Insurance No. ...................
I, ............................................... (full name of appellant) of ......................................... (address of appellant)
Appeal against the decision on ....................................................... (date) of the medical board at ................................. (address) notified to me by letter (from ............................) dated ...................
that:-
*(1)
there is no appreciable disablement;
*(2)
the disablement should continue to be treated as temporary and the next date when the case should be referred to the Medical Board is; or
*(3)
the disablement can be declared to be of a permanent nature; and
( i ) the extent of loss of earning capacity can be assessed provisionally or finally,
(ii) the assessment of the proportion of loss of earning capacity whether provisional or final; and
(iii) in case of provisional assessment, the period for which such assessment shall hold good.
The following are the grounds of my appeal:
List of documents, if any:
Date ............................................ Signature of appellant
*Delete whichever does not apply.
The statement of facts contained in this application is to the best of my knowledge and belief true and correct.
Signature of appellant