How to write an application for work related injury determination, and how to write an application f

Application for authorization.

Legal representative: Position.

Requests. The labor department is requested to determine that the applicant's injuries at the time are work-related injuries in accordance with the law.

Facts & Reasons:

The applicant is an employee of the company, was recruited into the company to work in the year, and during the working hours of the year, month, and day, because of a work accident in the company, the applicant was seriously injured. After the applicant was injured, he was hospitalized in a city hospital** and has been in the hospital for ** months now, spending medical expenses.

In accordance with the provisions of the "Regulations", the labor department is hereby requested to investigate and verify the applicant's injury, and determine that my injury is a work-related injury in accordance with the law.

Sincerely. County (city) departments.

Applicant (Signature):

20 years, months, and days.

If your rights and interests are damaged, you can protect your rights and interests through arbitration, and for specific details, you can log in to Cisco Law Firm** to inquire about the relevant legal provisions, or you can consult a professional lawyer to effectively solve the existing problems.

There is a standard to go to the ** labor department to ask for it.

The application for determination of work-related injury should be written in such a way as to state the applicant's identity and work information, as well as specific information about the work-related accident and injury. The specific process, cost and location after the accident. Finally, the application should be submitted and dated, signed and sealed.

Legal Representative: Position:

Request: Request that the applicant's injuries be determined as work-related injuries in accordance with the law.

Facts and reasons: The applicant is an employee of the company, signed a labor contract (established labor relationship) in January and year, and worked at the post. During the working hours on the day of the year, a work accident occurred at the location, resulting in serious injuries to the applicant's parts.

After the applicant was injured, he was diagnosed in the city hospital** and has been hospitalized for ** months, spending medical expenses.

In accordance with the provisions of the Regulations on Work-related Injury Insurance and the Measures for the Determination of Work-related Injuries, the labor department hereby applies to the labor department to investigate and verify the applicant's injury, and to determine that my injury is a work-related injury in accordance with the law.

Sincerely, the County (City) Labor and Social Security Bureau.

Attached: Relevant evidentiary materials.

Applicant (Signature): YYYYYYYYYYYYYYYYYYYYYYY

A brief description of the process of injury generally includes the basic information of the time, place, process, cause, location and extent of the injury. The following materials shall be submitted in an application for designation:

1) Application form for determination of work-related injury;

2) Proof of the existence of an employment relationship (including a de facto employment relationship) with the employer;

3) Medical diagnosis certificate or occupational disease diagnosis certificate (or occupational disease diagnosis and appraisal certificate).

The application form for determination of work-related injury shall include basic information such as the time, place, and cause of the accident, as well as the degree of injury of the employee.

Where the materials provided by the applicant for work-related injury determination are incomplete, the social insurance administrative department shall inform the applicant of all the materials that need to be supplemented and corrected in writing at one time. After the applicant requests to supplement and correct the materials in accordance with the written notice, the social insurance administrative department shall accept it.

Legal basis

Article 17 of the Regulations on Work-related Injury Insurance.

If an employee is injured in an accident or is diagnosed or appraised as an occupational disease in accordance with the provisions of the Law on the Prevention and Control of Occupational Diseases, the unit to which he or she belongs shall, within 30 days from the date of occurrence of the accident injury or the date of diagnosis or appraisal of an occupational disease, submit an application for recognition of work-related injury to the social insurance administrative department of the coordinating area. In case of special circumstances, the time limit for application may be appropriately extended with the consent of the social insurance administrative department.

If the employer fails to submit an application for recognition of work-related injury in accordance with the provisions of the preceding paragraph, the injured employee or his close relatives or trade union organization may, within one year from the date of occurrence of the accident injury or the date of diagnosis or appraisal of an occupational disease, directly submit an application for recognition of work-related injury to the social insurance administrative department of the coordinating area where the employer is located.

Matters that shall be determined by the provincial-level social insurance administrative department in accordance with the provisions of the first paragraph of this Article shall be handled by the social insurance administrative department at the districted-city level where the employer is located in accordance with the principle of territoriality.

If an employer fails to submit an application for determination of work-related injury within the time limit specified in the first paragraph of this Article, the employer shall bear the relevant expenses such as work-related injury benefits incurred during this period that comply with the provisions of these Regulations.

The application for determination of work-related injury should have seven contents. The details are as follows:

3. The position of the legal representative;

4. Requests;

5. Facts and reasons;

6. Signature of the applicant;

7. The date on which the application for determination of work-related injury was concluded.

If the employer fails to issue an accident report and apply for work-related injury recognition in accordance with the regulations, the injured employee or his relatives may apply to the labor and social security bureau where the business license of the enterprise is registered to apply for work-related injury identification.

Individuals applying for work-related injury determination must bring the following materials:

1. A valid written labor contract between the employee and the employer, or a certificate of de facto labor relationship;

2. Application for Identification of Work-related Injuries of Employees;

3. Employee's ID card and work permit;

4. Materials on injuries and accidents of employees or employers;

5. Relevant circumstantial evidence.

Legal basis] Regulations on Work-related Injury Insurance

Article 14 In any of the following circumstances, an employee shall be deemed to have suffered a work-related injury:

1) Being injured in an accident during working hours and in the workplace due to work-related reasons;

2) Being injured in an accident while engaging in work-related preparatory or finishing work in the workplace before or after working hours;

3) Injured by violence or other accidents during working hours and in the workplace due to the performance of work duties;

4) Suffering from occupational diseases;

5) Injured or unaccounted for in an accident while away for work;

6) Injured in a traffic accident or an accident involving urban rail transit, passenger ferry, or train for which they are not primarily responsible;

7) Other circumstances that laws and administrative regulations provide shall be recognized as work-related injuries.

An individual's written application for work-related injury determination shall state the following contents: 1. Indicate the applicant's information; 2. Request: request the arbitration institution to evaluate the disability level of XX; 3. Explain the facts and reasons; 4. Conclusion: Sincerely, the labor and social security administrative department.

Legal basis

If the employer fails to submit an application for work-related injury recognition in accordance with the provisions of the preceding paragraph, the injured employee, his close relatives or trade union organization may, within one year from the date of occurrence of the accident injury or the date of diagnosis or appraisal of an occupational disease, directly submit an application for work-related injury recognition to the labor and social security administrative department of the co-ordinating area where the employer is located.