THIS AGREEMENT is made at __________ on this ______ day of ___________, 2000, 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 X 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 the workman was employed by the employer in its factory in the capacity of ___________ and on ________ he was injured by 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.

WHEREAS 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.


(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 beforementioned 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.

The common seal of ABC Co. Ltd. has been hereunto affixed pursuant to the Resolution of its Board of Directors dated the _____ day of
__________, 2000, in the presence of S/Shri

______________ and _________________

Directors who have signed in token thereof.

Signed and delivered by A, the withinamed workman







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