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