In our current society, applications are more and more closely related to us. The application is a special letter, bearing our wishes and requirements. Do you know the format of the application? The following is an application for work-related injury and disability appraisal that I have compiled for you. Welcome to read the collection.
Application for work-related injury and disability appraisal 1 1. First, go to the social security department of the county (city) Labor and Social Security Bureau to receive the confirmation form of work-related injury application, and fill in the form in detail, including requiring the company to stamp and agree to the work-related injury identification.
Two, because of work-related injuries to apply for labor ability appraisal, the employer, work-related injuries or their close relatives or their agents shall apply to the municipal labor ability appraisal committee within the following time limit:
(a) if a work-related injury has been identified before the end of medical treatment, an application shall be filed within 30 days after the end of medical treatment;
(two) after the end of medical treatment, it shall be identified as a work-related injury, and it shall apply within 30 days after the identification of the work-related injury;
(three) the application for the identification of the recurrence of old injuries shall be made after the occurrence of the disease and before the end of treatment.
Three, to apply for identification of disability rating due to illness or non work, and apply in accordance with the relevant provisions of the time limit.
Four, the conclusion of labor ability appraisal is made one year later, if the injured workers or their close relatives, their units or social insurance agencies think that the disability situation has changed, they can apply to the Municipal Labor Ability Appraisal Committee for labor ability review and appraisal.
If the appraiser or his close relatives apply, the appraiser shall have completed the shortest medical treatment period for work-related injuries and his condition is relatively stable;
If the employer applies separately, the appraiser shall have completed the longest medical treatment period for work-related injuries and his condition is relatively stable.
Seriously injured, can also be introduced by the social security department, to the labor ability appraisal committee for disability appraisal. According to the results of work-related injury identification, the injured can get compensation for related losses caused by work-related injuries.
I am here to convey
welcome
Applicant:
Date:
Application for work-related injury and disability appraisal 2 Applicant: name, nationality, date of birth, hometown, home address, telephone number, application for work-related injury and disability appraisal.
Request: Request the people's court to entrust an appraisal institution to appraise the applicant's disability level, lost time, number of nurses, nursing period and follow-up treatment expenses.
Facts and reasons:
The case of the dispute between the applicant and Zhang Qianwan over the liability for motor vehicle traffic accidents has been submitted to your hospital for acceptance. The applicant was seriously injured in this accident, resulting in intracranial hemorrhage, lung contusion and laceration and fracture of the right lower limb. After receiving treatment in the hospital, although the treatment ended, IQ has been affected so far. After the fracture of the right lower limb healed, the right lower limb was shorter than the left lower limb, and the movement was inflexible, so it could not return to normal function. In order to claim compensation, the applicant now needs to identify the disability level, the number and time of nurses and the follow-up treatment expenses, so as to determine the disability compensation, lost time, nursing expenses and follow-up treatment expenses. Please arrange an appraisal in your hospital.
I am here to convey
Guigang gangbei district people's court
Applicant:
date month year
3. Applicants applying for work-related injury and disability appraisal:
Legal representative:
Address:
Request: Request the arbitration institution to appraise Wang AA's disability grade.
Facts and reasons:
Wang AA is an employee of the applicant's company and works in a production position. On February 7th, 20xx, Wang AA suffered an industrial accident in the workplace due to negligence. After the accident, the applicant actively rescued Wang AA. Wang AA entrusted Guangdong XX Judicial Appraisal Institute for disability appraisal on April 20xx 1, and the appraisal result was grade 9. But in fact, Wang AA had an old injury in the same injured part before the industrial accident, so the applicant thinks that the above appraisal results are not in line with the facts, and the applicant should not be responsible for his old injury.
According to the relevant laws and regulations, we now apply to an arbitration institution to investigate and verify Wang AA's disability and make a fair and reasonable appraisal result according to law.
I am here to convey
ZZ XX District Labor Dispute Arbitration Commission
Applicant: XX
date month year
Application for Work Injury and Disability Appraisal 4 Applicant: _ _ _ _ _ _ _
Legal Representative: _ _ _ _ _ _
Address: _ _ _ _ _ _
Requested items:
Request the arbitration institution to appraise Wang's disability grade.
Facts and reasons:
Wang _ _ _ _ is an employee of the applicant's company and works in a production position. After the accident, the applicant gave active treatment to Wang Jin. On _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
According to the relevant laws and regulations, we now apply to an arbitration institution to investigate and verify Wang's disability and make a fair and reasonable appraisal result according to law.
I am here to convey
Applicant: _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Application for work-related injury and disability appraisal 5 _ _ _ _ Municipal Human Resources and Social Security Bureau:
I am _ _ _ _ _ _ _ _, male, Han nationality, born on _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. Who lives in _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
I am _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ The hospital initially diagnosed incomplete fractures of the fourth and fifth toes, greater trochanter of the third toenail and fracture of the fifth metatarsal bone. He has been discharged from the hospital and is undergoing rehabilitation training.
Now it is necessary to handle industrial injury insurance compensation and other related matters, and hereby apply for labor ability appraisal. Thank you for handling!
I am here to convey
welcome
Applicant: _ _ _ _ _ _ _ (signature and handprint)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Application for work-related injury and disability appraisal 6 Applicant: Zhang xx, lawyer of xxxx.
Address: Floor 9, Zone C, xxxxx Plaza
Tel: 057 1-xxxxxx Fax: 0571-XXXXXX.
Application items:
The applicant, as the defender of Wu's intentional injury case, has objections to the forensic biopsy certificateNo.. (20xx) No.068, and now apply for re-appraisal of the facts and reasons:
The documentNo. of forensic living examination is "Examination". (20xx)068 issued by the forensic witness room of a city public security bureau shows that the examinee "sees a large area of hypertrophic scar and pigment change from the left forehead to the left neck (in front of the left auricle)-18* 15cm, with obvious left mandible and neck and limited neck movement". Its "inspection opinion" is based on the fourth paragraph of Article 16 of the "Standards for Identification of Serious Human Injuries" to assess serious injuries.
Article 16, paragraph 4, of the Appraisal Standard for Serious Injuries of Human Body stipulates: "Scar contracture caused by second-degree deep burns on the face and neck, which significantly affects the face or seriously hinders the activities of the neck."
The applicant thinks that (20xx)068 Forensic Biopsy Appraisal only recognizes that the patient's neck movement is limited; However, "limited neck movement" and "severe neck movement disorder" are not the same, and the difference between them is obvious. At the same time, it did not show that the patient "caused scar contracture after injury, which had obvious influence on the face". Therefore, the applicant believes that the injury of the victim Zong Moumou in this case did not reach the level of "scar contracture significantly affects the face after injury" or "serious obstacle to neck movement", and the injury of the injured person did not meet the constitutive requirements of "human body serious injury appraisal standard" and did not constitute serious injury.
At the same time, the applicant believes that the victim Zong Moumou's injury conforms to Item (2) of Article 45 of the secondary appraisal standard for human minor injuries, "The head, hands and perineum are burned and scalded more than twice, which affects the appearance, appearance or activity function." Provisions, constitute a minor injury.
According to Article 159 of the Criminal Procedure Law, "during the court hearing, the parties, defenders and agents ad litem have the right to apply for notifying new witnesses to appear in court, for obtaining new material evidence, and for re-appraisal or inspection." The defender is required to apply for re-appraisal of the victim's injury.
I am here to convey
Salute!
XXX people's court
Applicant: Lawyer Zhang.
20xx June 20th
Application for work-related injury and disability appraisal 7 xx Labor Ability Appraisal Committee:
I am an employee of xx (employing unit), and my ID number is xx. I was injured at work on xx, xx. After treatment and medical treatment, I now apply for labor ability appraisal, please apply.
I am here to convey
Salute!
Applicant:
Xx，xx，XX，XX
Application for work-related injury and disability appraisal 8 Applicant:
Legal representative:
Address:
Request: Request the arbitration institution to appraise the disability level of Wang Moumou.
Facts and reasons:
Wang is an employee of the applicant's company and works in a production position. During the working hours of XXxx, xx and xx, an industrial accident occurred in the workplace due to negligence. After the accident, the applicant actively treated Wang Moumou. On, Wang entrusted Guangdong XX Judicial Appraisal Institute to carry out disability appraisal, and the appraisal result was Grade 9. But in fact, Wang had an old injury in the same injured part before the industrial accident, so the applicant thinks that the above appraisal results are not in line with the facts, and the applicant should not be responsible for his old injury.
According to the relevant laws and regulations, we now apply to an arbitration institution to investigate and verify Wang's disability and make a fair and reasonable appraisal result according to law.
I am here to convey
XX District Labor Dispute Arbitration Commission
Applicant:
Date, year and month
Application for work-related injury and disability appraisal 9 xxx Provincial Committee for Labor Ability Appraisal:
Xxxx employees of our company; Gender: male/female; Id number: xxxxxxx. I was injured at work on xx, xx, xx, and went to xxx State Labor Ability Appraisal Committee for appraisal after treatment. The comprehensive evaluation result is disability XX. As far as our company knows, the patient is now recovering well, no different from normal people and working normally. Therefore, our company does not recognize the appraisal result, and hereby applies to the xx Provincial Labor Ability Appraisal Committee for re-appraisal of xxxx's labor ability. Hope for approval!
Hereby apply!
I am here to convey
Salute!
Applicant:
Xx，xx，XX，XX
Application for work-related injury and disability appraisal 10 Applicant: Yan Mou, male,1born on May 29th, 969, Han nationality, now living in184th regiment, ID number: 4210811964. Yan, male, 1972 10, 17, born in June, Han nationality, now living in 184 regiment, ID number 421081196994. Respondent: Legal Representative of Respondent: Legal Representative Position: Address: Tel:
Request: Request that the death of Yan, the younger brother of the applicant, on September 26th, 20xx be recognized as work-related injury death according to law.
Applicant (signature):
Date, year and month
Application for work-related injury and disability appraisal 1 1 xx labor ability appraisal committee:
Applicant: Male, Han nationality, born on xx, xx, now living in xx, with the ID number of xx, who is an employee with work-related injuries in xxxxx. Tel: XX.
Application matters; Disability grade appraisal
Reason for application: On xx, xx, xx, the applicant was injured in the left eye by the rebound of the iron wire when unloading the cooling water pipe at the end of the shearer in XX working layer, and was diagnosed as: right foot rolling; Blunt contusion of left eye: 1, bulbar conjunctival laceration, 2, multiple foreign bodies in conjunctiva, 3, optic nerve contusion, which belongs to industrial injury. The applicant's injury is basically stable and has been discharged. So far, the applicant has a headache, his left eye can't see things clearly (more than half a meter), and his working ability has obviously decreased, which has brought great inconvenience to his future life and work.
The injury suffered by the applicant was identified as a work-related injury by the Qinglong County Human Resources and Social Security Bureau (Decision on Work-related Injury Identification (Qingrenshe Work-related Injury Identification Word (20xxx) No.070), and I hereby apply to the Southwest Guizhou Labor Ability Appraisal Committee. I sincerely hope that you will safeguard the legitimate rights and interests of the applicant and give the applicant a disability grade appraisal.
I am here to convey
Salute!
Applicant:
Xx，xx，XX，XX
Application for Appraisal of Work-related Injury and Disability 12 xx Labor Ability Appraisal Committee:
I am an employee of xxx (employing unit), and my ID number is xxxx. I was injured at work on X, X, X, and after treatment and medical treatment, I now apply for labor ability appraisal. Please handle it.
Applicant (signature): xxx
X year x month x day
Unit opinion: xxx
Seal of unit:
X year x month x day
Knowledge expansion: application notes for industrial injury disability grade appraisal
I. Application procedures
Employers, employees with work-related injuries or their close relatives (hereinafter referred to as the applicant) can only submit the work-related injury disability grade appraisal to the Municipal Labor Ability Appraisal Committee 60 days after receiving the work-related injury determination decision (effective).
The applicant may entrust a lawyer or other agent to apply for labor ability appraisal. Where a lawyer or other agent is entrusted to apply for labor ability appraisal, a power of attorney shall be submitted to the Municipal Labor Ability Appraisal Committee.
Second, the application materials
1, original and photocopy of the work-related injury determination decision.
2. Fill in an application form for industrial injury and disability grade appraisal in Puyang.
3. If the applicant is an employee with a work-related injury, provide the original and photocopy of the identity certificate; If the applicant is a close relative of an injured worker, provide a certificate of close relationship; If the applicant is a unit, it shall provide the approval document and photocopy of the establishment of the unit (stamped with the official seal of the unit), the original and photocopy of the ID card of the agent, and the power of attorney of the unit.
It is necessary to understand the related contents of industrial injury appraisal. The procedure of work-related injury appraisal, the application time of work-related injury appraisal and the specific cost of work-related injury appraisal are all the contents you need to master. The specific content is involved in the legal knowledge section of the website. Please visit the legal knowledge section of the website for details.
Application for work-related injury and disability appraisal 13 (1) application for work-related injury appraisal;
(two) the identity certificate of the employees;
(3) proof of labor relations with the enterprise;
(4) Preliminary medical diagnosis certificate or occupational disease diagnosis certificate (or occupational disease diagnosis appraisal certificate);
If an employee is unable to apply for work-related injury identification by his immediate family members or trade unions, he shall also submit the identity certificate of the applicant and the certificate of the relationship between the applicant and the employee with work-related injury.
In any of the following circumstances, the applicant shall also submit the certification materials issued by the relevant departments:
(1) If it is a traffic accident, it shall submit the conclusion certificate of accident responsibility recognized by the public security traffic police management department;
(two) engaged in emergency rescue, rescue and other activities, safeguard the interests of the state, society and the public, and submit the certificate issued by the civil affairs and public security departments;
(3) If a soldier who is disabled in the line of duty or because of war is demobilized and transferred to work in an enterprise, he shall submit a disability certificate and a diagnosis certificate of recurrence of old injuries in a designated hospital;
(4) If he is missing on business, he shall submit a certificate of death declared by the people's court;
(five) personal injury caused by the performance of duties, submit a certificate issued by the public security organ or the people's court; (six) other documents that need to be submitted under special circumstances.
If the materials provided by the applicant are incomplete, the administrative department of labor security shall inform the applicant in writing of all the application materials that need to be supplemented at one time.
I am here to convey
welcome
Applicant:
Date:
Application for Appraisal of Work-related Injury and Disability 14 ____ _ Committee for Appraisal of Labor Ability:
Applicant: Male, Han nationality, born on.
Application matters; Disability grade appraisal
Reasons for application: on _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ The applicant's injury is basically stable and has been discharged. So far, the applicant has a headache, his left eye can't see things clearly (more than half a meter), and his working ability has obviously decreased, which has brought great inconvenience to his future life and work.
The injury suffered by the applicant was identified as a work-related injury by the Qinglong County Human Resources and Social Security Bureau (Decision on Work-related Injury Identification (Qingrenshe Work-related Injury Identification Word (20 _ _) No.070), and I hereby apply to the Labor Ability Appraisal Committee of Southwest Guizhou. I sincerely hope that you will safeguard the legitimate rights and interests of the applicant and give the applicant a disability grade appraisal.
I am here to convey
welcome
Applicant:
Date:
Application for Appraisal of Work-related Injury and Disability 15 Applicant: _ _ _ _ _ _ _
Defendant: _ _ _ _ _ _
Legal Representative: _ _ _ _ _ _
Address: _ _ _ _ _ _ _ _ _ _ _
Requested item
Request for disability grade appraisal of the applicant according to law.
Facts and reasons:
The applicant and the respondent signed a labor contract, and the respondent sent them to _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. After the accident occurred on a certain day in _ _ _ _ _ _ _ _ _ _ _ _ _ _, the respondent actively rescued the applicant, and the treatment has ended. According to the relevant laws and regulations, we hereby apply for your company to appraise the disability grade of Wang _ _ _ _ _. I hope to be recognized.
I am here to convey
Applicant: _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _