FORM OF AGREEMENT BETWEEN THE EMPLOYER AND WORKMAN REGARDING

FORM OF AGREEMENT BETWEEN THE EMPLOYER AND WORKMAN REGARDING

FORM OF AGREEMENT BETWEEN THE EMPLOYER AND WORKMAN REGARDING

FORM OF AGREEMENT BETWEEN THE EMPLOYER AND WORKMAN REGARDING

COMPENSATION FOR PERMANENT DISABLEMENT

Form L
[See rule 48]
Memorandum of Agreement

It is hereby submitted that on the………………day of………………20…….. personal injury was
caused to………… residing at…………………………..by accident arising out of and in the course of
his employment in The said injury has resulted in permanent disablement to the said workman of
the following nature namely:
The said workman’s monthly wages are estimated at Rs . …………………………………. The workman
is over the age of 15 years/ will reach the age of 15 years on . The said workman has,
prior to the date of this agreement, received the following payments, namely:
Rs ………………on………………Rs ………………on………………
Rs ………………on………………Rs ………………on………………
Rs ………………on………………Rs ………………on………………

It is further submitted that………………the employer of the said workman has agreed to pay and,
the said workman has agreed to accept the sum of Rs ………………in full settlement of all and
every claim under the Workmen’s Compensation Act, 1923, in respect of the disablement stated
above and all disablement now manifest. It is, therefore, requested that this memorandum be duly
recorded.
Dated………………20………………
Signature of employer …………………………………………………………………………………………
Witness …………………………………………………………………………………………………………….
Signature of workman …………………………………………………………………………………………
Witness …………………………………………………………………………………………………………….

Note.‐ An application to register an agreement can be presented under the signature of one
party, provided that the other party has agreed to the terms. But both signatures should be
appended, whenever possible.
Receipt (to be filled in when the money has actually been paid).
In accordance with the above agreement, I have this day received the sum of
Rs………………
Dated………………20……..
………………Workman
The money has been paid and this receipt signed in my presence.
…………………Witness
Note.‐ This form may be varied to suit special cases, e.g., injury by occupational disease,
agreement when workman is under legal disability, etc.