Application for industrial injury identification

Applicant: * * *, sex x, X * * * month * * birth, nationality *, native place, * * * city * * * street, ID card number: * * *, staff of * * company.

Contact telephone number x x x x.

The applicant: XXX company, address: X * * * * *.

Legal representative: * * x * * * duty

Contact number: x x x x x x

Request items

The labor department is required to be injured according to law.

Facts and reasons:

The applicant is an employee of XXX company. He was recruited into the company by XXXXXXXX and worked as a * * on the date of working on the day of the month, because the company suffered a serious accident.

After being injured, he was hospitalized in * * city * * hospital, and has been treated for x months.

According to the provisions of the industrial injury insurance Ordinance, the labor department has applied for investigation and verification of the applicant's injury, and has legally confirmed that the injury was a work-related injury.

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