Form XVIII A

(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 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 Act 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 Act are unaffected by this agreement it is, therefore, requested that

this memorandum be duly recorded.

Dated ................ 20......

Signature of employer

Witness

Signature of employee

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........

Employee

Dated ..................20…...

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.