Labour Law Form Of Agreement Between The Employer And Workman Regarding Compensation For Injury Caused To Workman By Accident

Form of Agreement between the Employer and Workman Regarding Compensation for Injury Caused to Workman by Accident

It is hereby submitted that on the______________________________________ Day of____________________________, 2000, personal injury was caused to_____________________________________ residing at____________________ by accident arising out of and in the course of employment during on_________________________________________________________________

The said injury has resulted in temporary disablement to the said workman whereby it is estimated that he will be prevented from earning more than of his previous/ any wage for a period________________________________ Months. The said workman has been in receipt of half-monthly payments which have continued from the_______________.day of_________________________200- until the___________________________day of______________________________ 200-, amounting total of Rs___________ The said workman's monthly wages are estimated at Rs_________________ The workman is over the age of 25 years. It is further submitted that____________________________ I, 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 all disablement of a temporary nature arising out of the said accident, whether now or hereafter to become manifest. It is, therefore, requested that this memorandum be duly recorded.

Dated________________________

Signature of employer__________________________________________________

Witness_________________________________________________________________________

Signature of workman______________________________________

Witness_________________________________________________________________________

Receipt (to be filled in when the money has actually been paid)

In accordance with the above agreement, I have on this____________ day of __________ received the sum of Rs__________

Dated ____________200 .

_____________________________workman

The money has been paid and this receipt signed in my presence.

_____________________________witness

*The form may be varied to suit special cases, e.g., injury by occupational disease agreement when workman is under legal disability etc.