In a progressive society, application is closely related to our life. Please note that different types of applications have different formats. In order to spare you the headache of writing an application, the following is a sample of work-related injury application I collected for you, hoping to help you.

Work-related injury application 1 applicant:

Respondents:

Requested items:

1. Request to confirm that the labor relationship between the applicant and the respondent has been dissolved in accordance with the law since 20xx65438+1October 29th, and ask the respondent to pay the applicant an economic compensation of 3,480 yuan for dissolving the labor contract (1740 yuan x 2).

2. Ask the respondent to pay the applicant's level 7 industrial injury treatment 170 1 12 yuan. Mainly includes the following items:

(1) The medical subsidy for work-related injuries is 39,886 yuan (65,438 yuan+X2,849 yuan in April).

(2) Disability employment subsidy of 38,976 (80 yuan x2 1.75 days x0.7x32 months).

(3) Disability allowance is 22,620 yuan (80 yuan x2 1.75 days x 65438+March).

(4) Request the ruling that the respondent shall pay the applicant 20,880 yuan (65,438+February x 1.740 yuan) during the work-related injury.

(5) Requesting the respondent to pay the nursing expenses and hospital food subsidy of 5750 yuan during the work-related injury of the applicant. Nursing expenses in 80 yuan X50 = 4000 yuan, and food subsidies in 50 yuan x0. 7x50 days = 1750 yuan,

(6) The transportation fee is 20xx yuan.

(7) The rehabilitation cost is 40,000 yuan.

Facts and reasons:

The applicant began to provide labor services for the respondent on February 10, 20xx. The labor post is a handyman in XXXX's new office building. The respondent did not sign a written labor contract with the applicant at the time of employment, and the salary was calculated according to the daily 80 yuan. Salary is paid at the end of each month, and the respondent pays the salary to the applicant in cash.

Controversial facts:

1On October 4th, around 20xx 1 15: 00, the applicant operated a machine with his colleague XXX*** according to the respondent's work arrangement to sort out the ground residue of the new office building in XXX. Due to the ground obstacle, the machine was out of control, and the applicant's right foot was sucked into the machine, resulting in disability. The respondent gave the applicant corresponding medical treatment afterwards, but denied that the applicant's injury accident was a work-related injury and refused.

In desperation, the applicant filed a labor arbitration with the Provincial Labor Arbitration Committee in accordance with relevant laws to confirm the existence of labor relations between the applicant and the respondent. Confirmed by the Provincial Labor Arbitration Commission, there is labor relationship between the two parties. The appellee refused to accept the appeal and was later confirmed as a labor relationship by the people's court. At present, the judgment has come into effect.

According to the judgment, the applicant filed an application for work-related injury identification with the Provincial Social Security Bureau. Upon examination, it was confirmed that the applicant's injury occurred in +65438+20xx year1October 4th, and it was identified as Grade VII disability by the Provincial Labor Ability Appraisal Committee. Because the respondent did not apply for social insurance and refused to pay work-related injury benefits. Now we apply for arbitration according to the provisions of Item (2) and Item (5) of Article 2 of the Labor Dispute Mediation and Arbitration Law. According to the provisions of Item (3) of Article 38 and Item (1) of Article 46 of the Labor Contract Law, the applicant dissolved the labor relationship with the respondent on 20xx 65438+1October 29th, and the' duration of labor relationship' was from February 20th, 20x65438 +00 to 20x65438+/kl. According to paragraph 6 of Article 30, paragraphs 1 and 2 of Article 33, paragraph 1 of Article 37 and paragraph 2 of Article 62 of the Regulations on Work-related Injury Insurance; Items (1), (2), (3) and (7) of Article 38 of the Social Insurance Law and the relevant provisions of industrial injury insurance in XXX Province require the respondent to pay the applicant's industrial injury benefits 170 1 12 yuan. The above facts are clear and the evidence is conclusive. Please give support to the Provincial Labor and Personnel Arbitration Commission.

Applicant:

Date:

Work-related injury identification application 2 Applicant:

Respondents:

Request: According to the law, the injury of applicant xxxxx is recognized as work-related injury.

Facts and reasons: xxx Company hired applicant Chen xxxx to work in xXXX Company on XX, XX, XX. Applicant Chen xx was injured in xxxxxx on XX, XX, XX, and was diagnosed as xxxxxx after being sent to people's hospital for examination and treatment.

Because the applicant has been injured during working hours due to work reasons, according to the first paragraph of Article 14 of the Regulations on Work-related Injury Insurance, we are now applying to your bureau for identification as a work-related injury.

Applicant: xxx

Xx，xx，xx，0xx。

Application for Work-related Injury Article 3 Applicants:

Respondents:

Requested items:

The application was executed first, and the respondent xx Company paid the unpaid salary of the applicant totaling ***XX yuan.

Facts and reasons:

The case of labor dispute between the applicant xx and the respondent xx Company appealed to the Labor Dispute Arbitration Committee of Shunde District, Foshan City on X, and the Labor Dispute Arbitration Committee of Shunde District of Foshan City accepted the appeal on X, and the labor legal relationship between xx and xx Company was clear. The respondent has been in arrears with the applicant's salary for nearly one year, which has caused the life of the applicant and his family to be in trouble and caused great mental pain and harm to the applicant and his family. If it is not implemented first, the life of the applicant will be seriously affected. Moreover, if the respondent refuses to pay the salary because of evasion, it will not be implemented after the first implementation, which will seriously damage the legitimate rights and interests of the applicant. In order to alleviate the urgent needs of the applicant, according to Article 44 of the Labor Dispute Mediation and Arbitration Law and Article 97 of the Civil Procedure Law of People's Republic of China (PRC), we now apply to the Labor Dispute Arbitration Committee of Shunde District, Foshan City for compulsory execution of the respondent xx Company.

Applicant:

X year x month x day

Application for Work-related Injury Identification 4 Applicant:

Respondent to the application

Requested items:

1. Request a ruling to dissolve the labor relationship between the applicant and the respondent.

2. Request for ruling that the respondent pays the applicant's work-related expenses totaling 105000 yuan.

Details are as follows:

1, a one-time medical subsidy of 3000 yuan x 65438+August.

2. A one-time employment subsidy of 3,000 yuan x September.

3. One-time disability allowance 3000 yuan x August.

Facts and reasons:

On August 6th, 20xx, the applicant was seriously injured in the leg while working for the respondent. Diagnosed by heshun county People's Hospital as a comminuted fracture of the left tibia and fibula and multiple soft tissue abrasions on the left calf. The respondent treated and cared for the applicant's injury, and at the same time identified it as a work-related injury. Under the organization of the respondent, the applicant was identified as Grade 9 disability by xx Labor Ability Appraisal Committee on 20xx 1.

Because the respondent failed to implement the complainant's industrial injury insurance benefits in accordance with the relevant regulations, it brought great harm to the applicant. In order to safeguard the legitimate rights and interests of the applicant, I hereby file a complaint with the Labor Arbitration Committee to support the applicant's request!

Applicant: xx

Xx year xx month xx day

Application for ascertainment of work-related injuries Article 5 Applicants:

Respondents:

Requested items:

It is requested that the injuries suffered by the applicant on 20xx165438+1October 3 be recognized as work-related injuries according to law.

Facts and reasons:

The applicant, Liu XX, is an employee of Xiangyang Animal Health Supervision Office. He joined the company in July 20xx and worked in Qilihe Quarantine Bureau for animal health supervision. Applicant Liu xx was violently attacked by the business owner during the working hours of 20xx165438+1October 3, resulting in the long left forehead of applicant Liu XX. 5 cm skin laceration and four stitches. Second-degree burns on the little finger, index finger and middle finger of the right hand and the ulnar side of the palm, with turpentine attached to many parts of the whole body. The applicant was treated in Xiangyang First People's Hospital after being injured. Diagnosed as:

1, scalp laceration.

2. Second degree burn of the right hand.

3. Multiple soft tissue injuries all over the body.

4. brain injury reaction. Spending 54 days in hospital 19253 yuan. After that, he went to the First People's Hospital of Xiangyang again on February 27th, 20xx due to a strong brain injury reaction. Diagnosed as post-traumatic syndrome. The medical expenses are 29 1.8 yuan, and the total medical expenses of the above two treatments are 19544.8 yuan.

According to the third paragraph of Article 14 of the Regulations on Industrial Injury Insurance, the applicant's injury belongs to industrial injury. In view of the applicant's initiative to apply for work-related injury identification, according to the second paragraph of Article 17 of the Regulations on Work-related Injury Insurance, he applied to the labor department for investigation and verification of the applicant's injury, and his injury was identified as a work-related injury according to law.

Therefore, I hereby apply to Xiangyang Labor and Social Security Bureau for verification and confirmation. Thank you very much!

Applicant (signature): Liu XX

Xx year xx month xx day

Application for Work-related Injury Identification 6 Applicant:

Respondents:

Request:

Facts and reasons:

Hubei Sanguo Chibi Tourism Development Co., Ltd. (hereinafter referred to as Sanguo Development Company, the same below) successfully obtained the construction right of the ancient garden construction project in San'guo City, Chibi. I don't know when the criminal suspect Xu Youhao (also known as Xu Xiong, the same below) forged the administrative seal of our company without the permission and authorization of our company, and signed a construction contract with Sanguo Development Company in the name of our company to obtain the construction contract right of this project. Without careful examination, the Three Kingdoms Development Corporation awarded the project to Xu Youhao without any qualifications and certificates. When the contract was concluded between them, the contents of the contract, when the plaintiff in the original trial had an industrial accident and was recognized as an industrial injury, the first and second administrative proceedings, until the chibi city People's Court (20xx) Chi Min Chu Zi No.420 filed, tried and decided, no one or any unit informed or summoned our company to participate in the litigation, and Xu Youhao forged our seal and other related procedures were completely unknown to our company. 20xx165438+1October 17, the staff of the executive court of chibi city people's court came to Daye to seal up, freeze and deduct our company's account 195925 yuan, and our company was unaware of the above situation. 20xx65438+On February 6th, the criminal suspect Xu Youhao was reported by the staff of the Three Kingdoms Development Corporation on suspicion of forging our company's seal, and was criminally detained and arrested by the chibi city Public Security Bureau. In fact, our company has nothing to do with the Three Kingdoms Chibi City project developed by the Three Kingdoms Development Corporation, and the plaintiff Zhang in the original trial has no labor relationship with our company. 20xx 10 13. Zhang was injured after work this afternoon, which has nothing to do with our company. Our company is a complete outsider.

Our company believes that the original judgment found that the factual evidence was insufficient and it was forged; The main evidence of the facts ascertained in the original judgment was not cross-examined. Now, our company has enough new evidence to overturn the original judgment. The judgment of chibi city People's Court (20xx) No.420 civil judgment is completely wrong and should be revoked and retried according to law.

Therefore, according to the provisions of Articles 177, 178 and 179 of the Civil Procedure Law, our company applies to your hospital for retrial according to law, requesting your hospital to cancel the civil judgment (20xx) Chiminchuzi No.420 according to law and decide to retry according to law, so as to safeguard the legitimate rights and interests of the applicant.

Applicant:

20xx65438+February 8th

Application for Work-related Injury Identification 7 Applicant:

Defendant:

Requested item

Request the labor department to determine that the applicant was injured in xxx as a work-related injury according to law.

Facts and reasons:

The applicant is an employee of xxx company, who was recruited into the company in xx in 20xx and worked in xx in 20xx. The applicant was seriously injured in a work-related accident in xx Company. After the injury, the applicant was hospitalized in xx Hospital, xx City, and has been treated for X months, spending xx yuan on medical expenses.

According to the Regulations on Industrial Injury Insurance, I hereby apply to the labor department for investigation and verification of the applicant's injury, and my injury is legally recognized as a work-related injury.

Applicant (signature): xx

Xx，xx，XX，XX

Work-related injury identification application 8 Applicant:

Respondents:

Request: Request that the injury suffered by the applicant in xxx (times) be recognized as work-related injury according to law.

Facts and reasons:

The applicant is an employee of xxx company, signed a labor contract (established labor relationship) on xx, xxxx, and worked in xx post. During the working hours of xx, xx, xx, an accident occurred there, causing serious injuries to the applicant's xx position. After the injury, the applicant was treated in xx hospital in xx city, and was diagnosed as xx. He has been hospitalized for xx months and spent xx yuan on medical expenses.

According to the Regulations on Work-related Injury Insurance and the Measures for Determining Work-related Injury, I hereby apply to the labor department for investigation and verification of the applicant's injury, and my injury is determined as a work-related injury according to law.

Applicant: xx

Xx，xx，XX，XX

Work-related injury application 9 Applicant:

Respondents:

Requirements: during the treatment of work-related injuries, wages are paid according to work-related injuries, not according to sick leave.

During the hospitalization 16 days, it cost more than 80,000 yuan, and the child could not find a team. In June, July and August, the salary of the team is calculated according to the business, including medical expenses subsidies, and the rest is paid according to sick leave.

The steel plate has not been taken out yet. Now, because my medical record is Qiao Yucun and my file is Shen Huaifeng, Beisu Coal Mine Hospital can't even open a sick note in order to standardize the sick note system. So I found a team in the first excavation area. Tang Xiangzhong said: "Your ID card name is inconsistent with the file name, so you can't report a work-related injury. This is stipulated by Yankuang Group. I have taken good care of you. If you want to report a work-related injury, you must first deduct the salary given to you by the team. " What should I do now?

I have no choice but to turn to you and ask the mine leaders to implement the industrial injury insurance regulations.

I am here to convey

Salute!

Applicant:

Work-related injury application 10 applicant:

Respondents:

Request: xxx

Request that the applicant be legally recognized as a work-related injury on xx, XX, XX.

Facts and reasons:

On XX, XX, XX, the applicant went to work for the respondent. At 1 1 p.m. on the evening of XX, XX, XX, the candidate's right pinkie was accidentally broken by a machine gear at work. After that, he was sent to X Hospital for treatment, during which he was hospitalized for several days and spent X yuan on medical expenses.

According to the third paragraph of Article 14 of the Regulations on Industrial Injury Insurance, the applicant's injury belongs to industrial injury. In view of the fact that the respondent did not take the initiative to apply for work-related injury identification, according to the second paragraph of Article 17 of the Regulations on Work-related Injury Insurance, I applied to the labor department to investigate and verify the applicant's injury, and determined my injury as a work-related injury according to law.

Applicant:

X year XX month XX day

Application for work-related injury identification 1 1 Dear xxx Education Committee,

Xxx, female, was born in xx month of xxxx, and worked in Ji Hua Middle School in xx month of xxxx. Now she is a first-class teacher in middle school. On the way to the classroom, I passed the door of the women's toilet on the second floor of the newly-built teaching building at around xx. Because the ground was wet, I fell to the ground. At that time, I felt pain in my left knee and my left leg could not bend. I was immediately sent to xx Hospital for treatment. Around xx, I was diagnosed as xx by the doctor and didn't do any treatment. Then after the expert consultation, I went to the orthopedic inpatient department of xx Hospital for plaster fixation. X-ray reexamination of xx showed no obvious bone joint, and the plaster was taken out. The doctor told him to do recovery exercises at home.

In view of this, I hereby apply for work-related injuries.

Applicant: xxx

Xx year xx month xx day