Form XVIII A

(See Rule 17)

Memorandum of Agreement

It is hereby submitted that on the .................... day of .................. personal injury was

caused to ....................... residing at ................... by accident arising out of said in the course

of employment in ............................................... . The said injury has resulted in temporary

disablement to the said employee, who is at present in receipt of wages amounting to Rs.

per month/no wages.

The said employee’s monthly wages prior to the accident are estimated at Rs.

............... . The employee is subject to a legal disability by reason of.

It is further submitted that the employer of the employee has agreed to pay and on

behalf of the said employee has agreed to accept half-monthly payments at the rate of Rs.

.............. for the period of the said temporary disablement. This agreement is subject to the

condition that the amount of the half-monthly payments may be varied in accordance with

provisions of the said code on account of an alteration in the earnings of the said employee

during disablement. It is further stipulated that all rights of commutation under Section 7 of

the said Code are unaffected by this agreement it is therefore requested that this

memorandum be duly recorded.

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

Witness Signature of Witness employer

Signature of employee

Note- An application to register and 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........

Employee

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

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

Note- This form may be varied to suit special cases, e.g., injury by occupational disease, etc.