The Code on Social Security (Mizoram) Rules, 2026
Form XVIII
Official text
Open in the official PDF (p. 51)
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(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 ..........................20.........
Signature of employer Witness
Witness
Signature or employee
Note- 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............
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.