FORM L
[See rule 48]
MEMORANDUM ON AGREEMENT
It is hereby submitted that on the day of 19 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 or 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, had 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 …………….. 19…………..
Signature of employer……………..
Witness ………… ………… …………
Signature of workmen…………….
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……
.................... Workman.
Dated………………19………….
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.
