It
is hereby submitted that on the...................................... Day
of............................, 2000, personal injury was caused
to..................................... residing at.................... by
accident arising out of and in the course of employment during
on................................................................The
said injury has resulted in temporary disablement to the said workman whereby
it is estimated that he will be prevented from earning more than of his
previous/ any wage for a period................................ Months. The
said workman has been in receipt of half-monthly payments which have continued
from the................day of........................200- until
the..........................day of.............................. 200-,
amounting total of Rs........... The said workman's monthly wages are estimated
at Rs................. The workman is over the age of 25 years. It is further
submitted that............................ I, the employer of the said workman
has agreed to pay, and the said workman has agreed to accept, the sum of
Rs...................... in full settlement of all and every claim under the
Workmen's Compensation Act, 1923, in respect of all disablement of a temporary
nature arising out of the said accident, whether now or hereafter to become
manifest. It is, therefore, requested that this memorandum be duly recorded.Dated.......................Signature
of employer..................................................Witness.........................................................................Signature
of workman......................................Witness.........................................................................Receipt
(to be filled in when the money has actually been paid)In
accordance with the above agreement, I have on this............ day of
.......... received the sum of Rs..........Dated
............200 ..............................workmanThe
money has been paid and this receipt signed in my presence..............................witness*The
form may be varied to suit special cases, e.g., injury by occupational disease
agreement when workman is under legal disability etc.