FORM OF NOTICE BY COMMISSIONER COMMUNICATING REFUSAL FOR REGISTRATION

FORM OF NOTICE BY COMMISSIONER COMMUNICATING REFUSAL FOR REGISTRATION

OF AGREEMENT BETWEEN

EMPLOYER AND WORKMAN REGARDING COMPENSATION

Form O

[See rules 49 and 50]

Take notice that registration of the agreement to pay compensation said to have been reached

between you…………and ………………on the………………20………………has been refused for

the following reasons, namely:

………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………

Dated………………20……..

Commissioner

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