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.

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This is a reference draft reproduced for study and adaptation. Court rules, court fees and the correct forum vary with the facts and the value of the claim, so have the document checked and filed by an advocate. A defective application can be returned or dismissed even when the case itself is good.

Our Labour & Employment team drafts and files these documents before the Calcutta High Court, city civil courts, magistrate, family and consumer courts in Kolkata. Our employment team drafts agreements and handles labour disputes.

Disclaimer: this page is a sample format reproduced for reference and study. It is not legal advice and does not create an advocate–client relationship.

Agreement Between the Employer and Workman Regarding

Using this format

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