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 employment in………………The said injury has resulted in temporary disablement to the said workman, who is at present in receipt of wages amounting to Rs ……..per month / no wages The said workman's monthly wages prior to the accident are estimated at Rs . .......... The workman is subject to a legal disability by reason of .................................
It is further submitted that………………the employer of the workman has agreed to pay and………………on behalf of the said workman has agreed to accept half monthly payments at the rate of Rs . ………………for the period of the said temporary disablement. This agreement is subject to the condition that the amount of the , half monthly payments may be varied in accordance with the provisions of the said Act on account of an alteration in the earnings of the said workman during disablement. It is further stipulated that all rights of commutation under section 7 of the said Act are unaffected by this agreement. 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, etc

Using this format

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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