Form XXIV

{See Rule 66}

Memorandum of agreement in case of permanent disablement

To,

The Competent Authority for Employee’s Compensation,

……………………………….

Sir/Madam,

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 employment in............The

sudden injury has resulted in permanent disablement to the said employee of the following nature-

……………………………………………………………………………………..

……………………………………………………………………………………..

The said employee’s monthly wages are estimated rupees............................ The employee is over the age of 15

years/ will reach the age of 15 years 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 rupees............................... in full settlement of all and every claim under the

Code on Social Security, 2020 in respect of disablement stated above and all disablement now manifest.

It is, therefore requested that this memorandum duly be recorded.

Date: Signature of employer

Witness of employer:

1.

2.

Signature of workmen

To,

The Career Centre,

............................................

Note :–

This return is to be rendered to the Career Centre (Regional) within 30 days after the end of the financial year

concerned by establishments/employers vide their obligation under the Code on Social Security, 2020 (Chapter XIII-

Empoyment Information and Monitoring).

The main purpose in obtaining the information from employers is to know

(i) the vacancies/employment opportunities available;

(ii) type of personnel who are in short supply; and

(iii) future job opportunities for providing vocational guidance to hte jobseekers and conecting them with the

employers. This is helpful in ascertaining the skill needs also. Employers too will be able to call on the Career Centre

for getting suitable candidates as per their requirements.

Witness of employee:

1.

2.

Note: An 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

(Receipt to be filled in when the money has actually been paid)

In accordance with the above stated agreement, I have this day received the sum of rupees............

Date:

Signature of employee

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

Signature of witness