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