Form XVIII

[See Rule 29]

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 ..........................20.......... Signature of employer 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 ...................20.... .

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.