THIS AGREEMENT is made at……………… on this………………day of………………20
………………between A B Co. Ltd, a company incorporated under the Companies Act, 1956 and having
its registered office at …. hereinafter called “the Employer” (which expression shall unless repugnant to
the context or meaning thereof include its successors and assigns) of the ONE PART and Shri A son
of………………resident of………………hereinafter called “the workman” (which expression shall unless
repugnant to the context or meaning thereof, include his heirs, executors, administrators and assigns) of
the OTHER PART
WHEREAS
(1) The workman was employed by the employer in its factory in the capacity of………………and
on………………he was injured in an accident arising out of and in the course of his employment, in
respect of which he claims that the employer is liable to pay him compensation under the Workmen’s
Compensation Act
(2) In order to avoid litigation in respect of the said claim, the parties hereto are desirous that the liability
of the employer (if any), shall be satisfied by the compensation herein agreed to be made.
NOW THIS DEED WITNESSETH THAT IT IS HEREBY AGREED AS FOLLOWS
(1) The employer shall pay the workman the sum of Rs . …………. as compensation for such injury as
aforesaid on ………….

(2) The employer shall also pay the workman the sum of Rs. ………………in respect of the costs of his
medical attendance and other expenses.
(3)The workman shall accept the before mentioned payments in full discharge of all liability of the
employer to pay compensation under the Workmen’s Compensation Act or any law for the time being in
force and doth hereby release the employer from any and all liability in respect of the injury caused to the
workman and from any and all liability for any damages, which may result to the said workman in future
on account of the said injury.
IN WITNESS WHEREOF, the employer hereto has set its hands and seal and the workman has set his
hands hereunto and to a duplicate hereof, the day and the year first hereinabove written.
WITNESSES
The common seal of ABC Co. Ltd. has been hereunto affixed pursuant to the Resolution of its Board of
1. Directors dated the………………day of in the presence of S/Shri …………
and………….Directors who have signed in token thereof
2. Signed and delivered by A, the withinamed workman