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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.



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