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.