Form XVIII

(See Rule 17)

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 employee’s monthly wages are estimated at Rs. .............................. The employee is

over the age of 15 years will reach the age of 15 years on ........................... .

The said employee has, prior to the date of the 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 employee has agreed to pay, and

the said employee has agreed to accept, the sum of Rs. .................... in full settlement of all

and every claim under the Code on Social Security, 2020 in receipt of the disablement stated

above and all disablement now manifest. It is therefore requested that this memorandum be

duly recorded.

Dated ..........................

Signature of employer Witness

Witness Signature or employee

Note- Application to register an agreement can be presented under 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 ...................

Employee

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 employee is under legal disability, etc.