FORM OF AGREEMENT BETWEEN THE EMPLOYER AND WORKMAN REGARDING COMPENSATION FOR TEMPORARY DISABLEMENT [CD1]
Form
M
[See rule 48]
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 employment in………………The said injury has
resulted in temporary disablement to the said workman, who is at present in
receipt of wages amounting to Rs ……..per month / no wages The said workman's
monthly wages prior to the accident are estimated at Rs . .......... The
workman is subject to a legal disability by reason of
.................................
It is further submitted that………………the employer of the
workman has agreed to pay and………………on behalf of the said workman 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 the
provisions of the said Act on account of an alteration in the earnings of the
said workman 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 workman
................................................................................................
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 ……………….
Dated
…………….....20............
………………........Workman
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, etc
[CD1]FORM OF
AGREEMENT BETWEEN THE EMPLOYER AND WORKMAN
REGARDING COMPENSATION FOR TEMPORARY
DISABLEMENT
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