(1) If in any case the Comm1ssioner refuses to record a memorandum of agreement. he shall briefly record his reasons for such refusal.
(2) If the Commissioner refuses to record a memorandum of agreement, he shall not pass any order directing the payment of any sum or amount over and above the sum specified in the agreement, unless opportunity has been gtven to the party liable to pay such sum to show cause why 1t should not be paid.
(3) Where the agreement Is for the redemption of half-monthly payments by the payment of a lump sum. and the Commissioner considers that the memorandum of agreement should not be recorded by reason of the inadequacy of the amount of such sum as filed tn the agreement, he shall record his estimate of the probable duration of the disablement of the workman.
52, Registration of memorandum accepted for record.-In recording a memorandum of agreement, the Commissioner shall cause the same to be entered in a register in Form Rand shall cause an endorsement to be entered under his signature on a copy of the memorandum to be retained by him In the followtng terms, namely:
'THIS MEMORANDUM OF AGREEMENT BEARING SERIAL NO .................... .
OF 20 ............. , IN THE REGISTER HAS BEEN RECORDED THIS ............. DAY OF ........... ..
FORM A (Rule 6 (IJJ Deposit of Compeuatlou for Fatal Accident Sd ...... ...... ..
Commissioner (Section 8 {l) of the Workmen's Compensatton Act, 1923)
1. Compensation amounting to Rs. . ............................ .... 1, preaented for deposit in respect of injuries resulung tn the dea workman whfch OCCUITed on ................................. whose Plll'Uculars beJow:
~········ .. •·~ Scanned by CamScanner 52 11fE WORKMEN CO PEN no RU . 192 (FonnAA-B Naine ............................... .
Father's/Husband· ((n ca ~ of married woman or Widow l name ............................... .
Caste ................................ .
Local add re ............... , ............... ..
Permanent address ............................... • Hts/Her monthly wag are esUmated at Rs ....................... when he/she was over /under the age of 15 years at the Ume of his/her death.
(2) The said workman had. prior to the date of his/her death received the followmg payments. namely:
Rs ..................... on dt. .... . ... ......... ... Rs ............ on dt. .... ... ... .
Rs ..................... on dL ...... .............. Rs ............ on dt. .. .. ... ... .
Rs ..................... on dt. ........ ..... ....... Rs ..... .. .... . on dt. .... .... . ..
Amounting tn all to Rs. .. .............. ............ ... ..
3. An advance of Rs. ........ ...... ...... has been made on account of compcnsatton to ........... bctng hts/her dependent. ·
4. I do not/desire to be made a party to the proceedings for distribution of the aforesaid CODlpensation.
Dated the .................... 20 ................... .
····· ··············· Employer Where an employer desires to be made a party the proceeding he should strike out the words "do not.• FORM AA (Rule 6 {l )J Deposit of Com,euatton for Non-fatal Accident to a WoJDaD or penon 1111der LetalDiaabWty .
ISecuon 8 (1) of the Workmen's Compensation Act. 1923 J I. Compensation amounting to Rs. . ...... .... ..... .. .. ls hereby presented for deposit In respect of tnjurles sustained by . . . . . .. . . . .. . . . .. .. . . .. ............. ... .
residing at ........................ ........ . on dt ... .. .. ........ ... .. 20 ............. :...... .
resulting In the Joss of/temporary disablement. His/Her monthly wages are estimated at Rs ..................... when he/she was over/under the age of 15 years at the time of the accident.
2. The said injured workman has pnor pafd to the date of the deposit received the half-monthly payments, namely:
Rs ..................... on dt. ................... .
Rs ..................... on dt. ................... .
Rs ..................•.. on dt. ................. .. .
Dated the .................... 20 ......... .
FORIIB (Rule 61 Rs ...... ...... on dt. .......... .
Rs . ..... ...... on dt ........... .
Rs . .......... . on dt . ... ...... . .
Employer Receipt for Com,euattoa (Depostt under Sectton B (JJ of the Workmen's Compensauon Act. JQ Receipt 11,, ............ .
~ ~ t-fq-q, 192 1'tfl: ..=-, ~o ••• •••••.••• ~ ............... , ........... .
cf>1 ~o ........ .. .. E ..........• ~::::::::::~::::::::::··· Scanned by CamScanner 53 1llE WORKME COMPE TION RULES. 1924 ~ -11-~ IFonn C- e Sum deposited Rs .............. .................... ... •· Dated the .. .......... ... 20 ......... .
FORMC (Rule 6) Statement of Dlabanements (Section (4} of the Workmen ·s Compensation Act. 1923/ Serial o . ............ ...... . .
Depositor ....... .... ....... . .
Date .... ............... .
Amount deposited ..... ...... ... .. ... . Rs.· ·· ············ ····· Amount deducted and re-paid to the employer under the provtso to Section 8 (1) ·••• ··· •·····•·· ··•· ·· ······· ··•···· ··•· Funeral expenses paid .... ............... .
Compensation paid to the followtng dependent (s):
ame Relationship ····· ···························· ······· ···· ········· ·· ·· ····· ············ ·· ·· ·· ······ ·· ················· ·· ············· Dated the ............. 20 ..... .. . .
Total ... .. ...... .. .. .. .. ..... .. .... .
············· ············· ····· Commissioner FORMD (Rule 91 Depodt of Compeaaation for Non-fatal Accidents, other than to a Woman or Person IIDder Legal Disability ISectton 8 (2) of the Workman·s Compensation Act. 1923/ Compensauon amounting to Rs . .................. Is hereby presented for deposit In respect of perman ent / temporary injuries sustained by d~t~::::::::::::::::::ii.'.'.'.'.'.:. residing at ............... ... wtth ..... ... .... .... .. occurred on Dated the .................. 20.... .... . ..... .... ... ... ..
FORME !Rule 91 Employer Receipt for Compematlon (Deposit under Section 8 (2) of the Workmen's Compensatton Act. 1923] Book No................... Receipt No................... Register No ............... ..
Depositor .....•••••.....•..
In favour of ................................. ..
Date of depoeJt the .................. 20 .......... .
Sum depoeited Ra. ....................... ..... , Dated tbe ........ .,.. . 20 • ~~~m .............................. .
~ .....•. ............... .. 20 ........... .
~11 (~61 ~cfil~IR (~~~. imifftml'I B (4)1 ifi'l~O• ••• • •• • •• •••••• ••••• •••••• •••• ~ .............................. .
~ ................................ .
~·~·~·~.-.-.·.·.·.-.::........... cfiM ~ ~ ~ ~ ~ ~ W-f1J mu s (1) -t ~ -t m ""'-=~~::.!'";;;. :: :::: :: :::
~ ....... . . ... ... ... .. ... . 20 ... ... ... .. .
~1( ········ •· ~~ ···•·······.
..... ······ ····· . [~ 91 ~-.;~~ ~ch1~~. ftt,m{fi Ci .. ,.,,_, ~ ~tu~:ltmffl-.; ~ cfif f.ll)'q ~ ,mcfft\lros(2)l ~~~ [~~ ...... .. .... . ~.~~ •• ~ .~: •....... ~o ~ ~ . ······ ................................ ctft ~ -t 1niffl ~~~·~-ami\tl ~ ~ .... .......... ...... ... . 20 .......... ..
~"S (~9) 1JftAS{-.'\* ~'<!Iii~) ~. 192315tttm8 (2) ~ 1'0 ............. .
(~~ -"io ............ ..
wc"o ... , ..... , ...
';I_,. • ••••• Scanned by CamScanner 54 To Sir.
11iE WORKME COMPENSATION RULES. 1924 PORMBE (Rule lI I Report of Fatal Accldenta (Form EE--F l. I have the honour to submtt the followtng report of an accident which , occurred on dated .................. 20 ............ , at.................. (enter detatls of premises).................. and which resulted In the death of the workman/workmen of whom particulars are given In the statement annexed hereto.
2. The Circumstances attending the death of the workman/workmen were as under:
(a) Ttme of the acctdent.
{b) Place where the accident occurred.
(c} Manner In which deceased was/were employed at the time.
{d) Cause of the accident.
(e} Any other relevant particulars Name Sex 2 STATEIIBNT Age 3 FORJIIF (Rule 201 I have, etc.
·················· ·················· Signature and designation of person making the report Nature of employment 4 Full postal address_ 5 Application for Compeuation by workman To the Commfssloner for Workmen's Compensation ........... _ ............................. residing at ....... : ............................... applicant versus .......... ........ ..................... residing at ................................ opposite party It ts hereby subntftted that-
(1) the applicant. a workman employed by ( a contractor With) the op~ite party on the ••..•••••.•.•...•. day of .................. 20 ............. , received ~r~ tnJwy by aeddent ari81ng out of and tn the course of his emp The cause of the injury was (tnsert briefly tn of the IIJlwy ) .. - ............................... .
fa) the appltc:ant,; &Qlttamed the fo ~ ~ t-fq-q. 1924 ~ 2 4 Scanned by CamScanner 55 11iE WORKME ·s COMPEN TION RULES. 1924 IFonnc
(3) the monthly wages of the applicant amount to Rs ................. ..
The applicant ts over/under the age of 15 years.
•(4) (a) Notice of the accident was served on the .. .. .. .. .. .. .. .... • of .................. 20....... day (bj Notice was served as soon as practicable.
(c) Notice of the accident was not served (in due time) by reason of
(5) The applicant Is accordingly entitled to recetve- (a} half-monthly payment of Rs. .................................... from the d of ····· ............. 20 ........ .. to......... ay {b) a lump sum payment of Rs ................. ..
(6) The applicant has taken the following steps to secure a settlement b agreement namely .................................... but tt has proved tmposstble ?
settle the questions In disputes because, .... .. . .... .... .. .. . .. .. . .... .. ... .. .... .. .. ... .. ... .. 0 d • You are, therefore, requested to determine the following questions 1 tspute, namely- n fa} whether the applicant Is a workman within the meaning of the Act· {b) whether the accident arose out of or tn the course of the appl;canr employment: s le} =:~ei the amount of compensation claimed ts due, or any part of that (d} :::ther the opposite party is liable to pay such compensation as ts (e} etc. (as reqUired) Dated the .................. 20 ............ .
•strt1ce out whichever clause ts not appli.cable.
FORM G (Rule 20) Application for Order to Deposit CompeDSation To Commissioner for Workmen's Compensation .................. residing at ................. , applicant:
versus .. · ............ • .. residing at .................. , opposite narty It is hereby submitted that- · Applicant part!,- 1~~-th~:::::::::: . .' .. ~.~;~~}1° employed by (a contractor With) the opposite by acctdent arising out of and in .th ............ 20 ........... , received personal injury death on the .................. day of e course of his employment resulting in his was (insert briefly tn ordinary lang ........... 2o ........... • The cause of injury .................. .................. uage the cause of uyury) ................ ..
(2) The applicant(s) is a/are dependant(s} of his.................. the deceased workman b~tng
(3) The monthly wages of th,. d----..
d ., ~ amount to Rs:
The eceaeeci~QW!r/. d · .......
(4) (aJ PUce f un er the age of 15 year, lb) .N d•wu serv~ o.o ~-i§) ~ ~ f'wl, 1924 55 9
(3) ~ctl-qifuq;~ ................. mtft,~3ltf:ft~t~,s<l1'~ 31f~1"itt '{II *(4) (~) ~~~~ .............. 20 .......... li~ ........ ~~~TP-lll (\I) ~~~mm~oo-11m~~TP-11,
(ll) ~~~ ................ .t'l~'{l(~~1R)~~~TP-111
(5) ~~- (~) ........... 20 ......... l; K-'t '{I .......... ~ ........ ~o t 31•~ 'f@R I (\I) ., ......... ~o l; ~ "f@R q,1W<!~li~~t, ~~~31'ffi\ ........... ~mlroq,1~t\~~~ <•: :;.: :! ::::!:!':«~:.,:om"':. fu< ~;.""' t a:i'ffil- (~) ql:ll~a:if~~a:i~~t,.
(1!i) ql:ll~~~~~<tl~~'tj~~I =~ctt ~~t<tl~ ~~~ ,wit, ~ ql:l'l-~u~~ ~ t (l.l) ql:llffipJ\~~~~"f@R~l;IBt1,~t°. ~ I (s'} ~(~fcl;~t) ~ ...................... 20 ......... .
~lJ [f.ltlq 20) ~ci;t~~~~-'qj~~ ~~~iii~ ~ ................................................ ~ ····················· ............................... .
Scanned by CamScanner 56 '1lfE RKME COMPE TION RULES. 1924 (FonnH~ (cJ a~~~~ ... ~~ .. ~~~ accident wa not served (tn due tlm I by reason (51 The deceased bet hi d of Rs................... ore s ath rec Iv d as compensation the total sum of ~~.:,~~1.~~~ l I /arc accon:ltngly entitled to receive a lump sum payment com~sa~~ o~h:ef:~· requested to award to the applicant Dated the .... ... :. ...... ~~2~~.~~Uon to which he may be entitled. the said • Stnlre out whtchever Is not appltcable. Applt~~t FORMH (Rule 201 Appllcation for Comm11Dication ISectton 7 of the Worlcme , To the Commissioner for Workm;·ss CCompensa~n Act. 19231 ompensation ...... ............ residing at .. . .. .. .. .. ... . ... . applicant; , uersus ...... ········ ···· residing at It 1s hereby submitted th;;~ ............ , opposite party
(1) The applicant/opposite payments from... .............. to party has been in receipt of half-m by accident arising out of ~d .j ... ii; .......... in respect of temporary disablonthly ( 2) The I n e course of his emplo""'ent ement app leant Is d i ::,••· · payments should be redeem:. rous that the right to receive half-monthly
(3) (a) The opposite party i to receive half-monthly paym~~~Willlng to agree to the redemption of the right rtghrJ The parties have been unable to to receive half-monthly payments s~~ ~gareddlng the sum for which the You are th fj r eemed.
' ere ore. requested to pass orders- (aJ directing that th redeemed: e right to receive half-monthly payments should be
(b) IJxtng a sum for the rede"ni payments. ptton of the right to receive half-monthly Dated the ................... 20 ........ ..
• • ·1 FORMJ (Rule 39) Whereas Notice Applicant .......... a clatm for compensauo has .._.. ... t............ and th n been made by ::!er Section i'i°.(2) of the e~aJ:,;. .... : ............ has clairn~·lli;t"·"" applicant, ~~ ~on°~: :ec:r:ai:~ ~t, 1923~':: ::~ .................. 20. d by lnfonned that vou may pay in res of e Mid__..__ ······--·• an , contest the -•-• " ~ fll __.tor the claim ror indemJd waam fqr JDUr 8PPQnmce you will be deemJd 't, IDalle by ~~ [fl'tll{ 20] '~~~~ qi1fcfiR~~cfil ························ ·· ··· .. ············ ..... R<ilrn ~ ............ .......... .... ... ................... ~ iR7TT ········· ....................................... R<ilrn ~ ............................................. f<Rl~ -q~ ~ ~ ~ -;;j@'( t f.!i ............................................. ...... .... .
(1) ~tfcmm~~~.~~~~~~~l)~3lfflR:
~ ~ 'i(fila ~ ................... . ~ ......... ....... ... . aq; 3lt-~ ~ WI <fi«l1 ~i-1 .
(2) ~~tf.!i31t-~1tzyhW!<m~~clil~~~~I .
(3) (<Ii) fcro~~alt~~macm~~~~l)~~t (l!I) ~~'Om~~-q~~~~Wl<rn~~ q,"(l:llf.@~~~~lRlt~'{HI am: ~ ~ t fcl;- (<li) ~fml~~fc1;3lt~~Wl'<m~~~~~~;
(l!I) ~-cfilm8~~~~~~~-um~<rn~~~ ffl <fit I ~ ................. 20............. ······················· ,9 Scanned by CamScanner 57 11-IE WORKMEN'S COMPEN no RU . I 24 IFonn JJ- K against the opposite party and your ltablll to lndemnt(v the oppo Ile party for any compensauon recovered from him.
Dated the ... ..... ... ..... .. 20........ .. ·· ·· ·· · ···· · ···· ·· FORMJJ [Rule 39) Notice Commtssloner Whereas a claim for compensation has been made by ...... .. ....... ... applicant, against .. ..... ........... and the said.. ...... .. ...... .. has claimed that you are liable under Section 12 (2) of the Workmen's Compensation Act, 1923. to Indemnify him against any compensation which he may be liable to pay In respect of the aforesaid claim, and whereas the said .. ....... ... ...... on notice served has claimed that you .. .... .. ... ....... stand to him In the relation of a contractor from whom the appltcant.. ... .... .... ... .. could have recovered compensation, you are hereby Informed that you may appear before me on dated .. ... ............. 20 .... ....... and contest the claim for compensation made by the said appltcant or the claim for Indemnity made by the opposite party .................. In default of your appearance you will be deemed to admit the validity of any award made against the opposite party ....... ............ and your liability to Indemnify the opposite party: ................ .
for any compensation recovered from him.
Dated the. .. ......... ... ... 20 ......... .
FORMK [Rule 48) Memorandum Of Agreement Commissioner It Is hereby submitted that on the .................. day of .................. 20 .......... , personal injury was caused to .................................. , residing at .................. by accident artstng out of and in the course of employment in .................. 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 respect of half-monthly payments which have continued from the .................. day of ················· ·20 ......... . , until the .......... day of ....... 19 ........... , amounting to Rs ................... in all. The said workman·s monthly wages are estimated at Rs ................... The workman 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 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 Compe~sation 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.
Witness.................. Signature of employer ................. .
Witness ................. . Signature of workman ................. .
Dated the .................. 20 ........ .
Note.-All applicaUon to regtster an agreement can be presented under the signature of one party. provided that the other party has agreed has Adr~cj ~ the terms. But both signatures should be appended, whenever poea1b.;;'" ~~~~ ~ ~~\ft-q" fl ~ .. ... ...... ...... 20 ............ .
Dq~ [~39) ~ ~ ....................... 'ili~~ ....................... t~ t ~ ~ ....................... ~ ~~~ t f4i 3TIT4~ ~ ~. 1923 12 (2) ~~~~M~cl,'\ ~~t~t-Jl'I~~ ~ ere cfil zytt ffl, ~ offi' ....................... ~ ~ ~ ll ~ ~ 't % 3lft{ ............ .. ......... ~ t ~ -q ffl ~ f ~ ~ ~~mil,~~~~~ t ~ 31111 ~ .................... 4., ........... .
q;1 ~ WlP..-1 ~ m, afR ~ ~ t ffl f.litl ~ ~ 3111<n fcrntft 1™ ....... .
~~ ~'iii~ i.fil~~laffli~~t~-q~~~Ri -q~ ..................... ~ cR@ ~ M ~ t ~ M ~ R'il ~ ~ ~q,l~~,, ~ ................. 20 ............ .
~'!'
[f.Ail 48) cfimc5'(~ M'al@lt°f.$~"~aft{~t(m;lp~il ....... .
~ :~ ......... ~ ~ ...................... 20 ........ t m ............ ~ ~ ~ . ·~~q,l'R~'ffiliffli.fi!<tiT\VliA\~lff~~~~ ·· ············· ~: 300~ ~ ~ ~~ q,1~~.~ '8 ~~ a ${~I ~ cfilfcfiR ~~WI qi«ll ~ t ~ ~ ................. 20 ........... t ~ ... ff•···~'ff 20 t ~............... ....... ~.
fG;nqi ................. ~•~•i•;ff•-.•~ 1fflff ~ ...................... ffl I ....................... ~ ~ 1 5qt1"31f\lqi~cliltl cfilfcfiR ~...................... ~ii~~ ~ ~: ~ t f.$ ...................... ff ~f.t!~\-:. ri ~ -~ f.Am ~q,l'ij\U°R:~~~~~ ·~~ff~151f.lli\'ff~ ii, ~ ~,ft~~ 1: -:·:~·~·,·;·~: ~ t fli 111A 1tAl1( 1-'I" ~ cl ~ qi01•111, tql"lll'I.
~fcfiilt~I ~ t\ffl\lt .. ................. .
~...................... ~t~ ...................... .
-~ ii ~ ~ 111 ffill t =r:~j• 5 Scanned by CamScanner 1liE URKM CO PE 110 RULES. 1924 IFonn L RECEIPT (To be filled m when the money has actually been paid) In accordance \\1th the abO\ agreement. I have this day the recetved the sum of Rs................... · · · · · · .... · ......
B ~ted the ....................... . 20............. Workman e money has been paid and this receipt signed In my presence ··············· Note.-This form b Wtt~~~ ..
Injury by occ . may e varted to suit special cases s disability. etc.upational diseases. agreement when work;;~ .. ;-- ............. e.g., s under legal FORML (Rule 48) It ts hereby submitt dMemorandam of Agreement foa:. ... ~.~·::.::::::.'.'.'.".:::·····~·· th;~.~~.~.~.:·::::•· .. r;~;~·~·~~j···;~·:• ............................ .
arising out of and ~.th ................ residing at. Jury was caused injury has resulted ln e course or his emplo~~~t·i~ ............. by accident follOWlng nature nam ly~ennanent disablement to th·~ ... ~d ............. The said Th . e . s workman of the e said workman·s month) The workman Is over y wages are estimated at Rs.................... .
...... .. .............. . The . the age of 15 years/wtll re h . .. ..
received the follOWing said workman has. prior to ~~ d the age of 15 years on Rs payments, namely: ate of his agreement, ::: ::::::::::::::::: : :; ::::··· .. . . :: ::::: :: ::::: ::·············· It Is further subrntttcd .............. Rs .............. on d ............. .
of the said workman has that ...... ............. ... .. ... .. t ............. .
accept the sum of Rs agreed to pay and. the ~d ................ , the employer the Workmen·s c .................. in full sett) workman has .. d ...... d t above and al ompcnsatton Act 192 ement of all and _....... o memorand l bedlsablements now ~ 3, In respect of the d::~ claim under um duly recorded est. It ls, therefore ement stated Witness ........... · ' requested that thts Witness ............ :::::· Signature of employer Dated the ...............
20 Signature of wo ....... • Note.-An ap 11 ........
••anature of one p cauon to register an But both etgnau!eaartyh, J)rOVtded that th~ 8 Ould be appended, .. ._ p ~-o) ~ ~ f'.m, 1924 58 ~ ....... _. ......... 20 ..... .... ... .
~ .srrz.-~~~cltit$ ....................... $~~*~~~~ ~ t ~*~"CR,~ ;;p.( 'U'TI ~ ~ ~ ~--q ~:1Riffl <Iii~ ' ~I ~~ [~48) cfm'{lfit~ ~ ~ M ~ t % ~ .............. 20 .............. $ m ........... ."I ............. ..
ii3ltR~~c{$(m;t~~"'· ...................... ~ .................... ~ ami1@ l;l@~lff ~ff~<t,'\~-w;;fcl~~~:fiill~~ iAI, ~:
ff~ <ti'\ l{IW<fi ~ ....................... ffl ~ 1'f'ft t, ff~,s~<filol\1l~~t~ ....................... ."11sd~311!~"'11 • ff~~ affl<im<ti'\~"''\'f~-Wl~~t • .o:
~ ............ ~ ............ 'fo, ......... ..
~ ............ ~ ............ 'fo ........... .
~ ............ "' ............ -. .......... .
59 q n Scanned by CamScanner d lh 1111, ·· ·w~;k·.;;~~ Dated the .................. 20 .......... .
The money ha, n paid and this receipt signed In my pres nee Wttn~~~ ote.-nu form may be varied to suit special cases. e.g.. Injury by occupaUonal diseases. agreement when workman ts under legal dtsab1llty, etc.
FORMM [Rule 48 [ Memorandum of Agreement •..... ~~ •. 1.~.~~~l .. ~~.~~~~~p::~;~ ~Jeu;;;·:;;~~··~~~~d··t~.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.. ~.~~.~~ 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 ................. ..... .
lt is further subnlltted that ....... ........... ..... ...................................... .
the employer of the workman has agreed to .... j;~;
and ........ ................. ......... .......... .. on behalf of the said workman has agreed to acx:ept 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 half-monthly payments may be vaned in accordance with the provisions of the said Act on account of an alteration in the earnings of the said workman dunng disablement. It is further stipulated that all rights of :~on under Section l of the said Act are unaffected by this agreement.
• ore. n:quested that this memorandum be duly recorded.
Witness ..... . ··· ·· ·· ······· · ·· Signature of employer ~!:.S~~·::::::::::::::::::: .... IS... .. ..... Signature of workman::::::::::::::::
stgna~7 application to register an agreement can be presented under the But both .,_,,:~e party. provided that the other party has agreed to the terms.
_,.-lures should be appended. whenever possible.
11b be m,_, RECEIPT In J'"""" fn when the money has achonll .. been paid I accordance With the abov ......._, of Rs........................ e agreement. l have this day received the sum B Dated the ........ - ..... 2() .......... ..
~.-~ 11111ffl, ~ - ft:R, - ~.
~-~ 'U11~ ~~ •• alff"~ 111-mwilhif!liia•--- t 1 W11'S [t!PA 48) ~-"""' ~~tf.li ...................... -4~~~ ~ ..................... ~m~ ..................... ~~ .............. .
~I~ '1fu~cfill;m~ ~f.l:fttltill~W11li4il1FI ----"' ....
~"MS<li«11\I Tii"ffl'R~'Sllftlcli~~~~ ..................... ~ I q,'tcffl~~f.l~~~t1 ~:~tfiliff~f.l:'ffim~~M-----~ ~"" cfill;milt ~ .................... 1m.) aftt151kiR • cm""~ 1' ~ f 1 ~nronlnRI • 3l'1A Os qqM · ffl'fflliffl~~-q~lll\~·ff~- cfit';ll(~t1•~= ~-'IJIRII·--~ ri~.mlRl~tl3Rl:~t11s~~.,_ ~...................... ~ TfiffW .................... ..
~ ...................... 20 ......... . ~-~1a~w.,_.. .. -w_.
~"W~°i-..'i1q•'8W'l'I _..swi- Scanned by CamScanner IForm N~ 60 ~""'"'N·S COMPENSA110N RUI..ES• 1924 rn&WO""'nu receipt signed tn my presence The money has been paid and this ...................... ..
Witness It special cases. e.g.. Injury by N te - This Corm may be varied to skmu an ts under legal dtsablltty, etc. · o . ent when wor occupauonal diseases. agreern FORM N [Rule 491 auon is said to have been reached Whereas an agreement to pay compe~d whereas .................... has/have between ........... ......... and ·· ···· ............ ~l under section 28 of the Workmen's applied for registration of the agr~meb given that the said agreement will be Compensation Act. 1923, notice is ere Y 20 ............ and that any objections to taken into consideration on ................. t .. , hould be made on that date. In the lhe registration of the said agreeme~te~Uon to proceed to the registration of absence of valid objections It ts my the agreement.
Dated the ............. ........ 20 .... ... .. Commissioner FORMO (Rules 49 and 50) Take notice that registration of the agreement to pay compensation said to have been reached between you .................... and .................... on the............. ...... .. 20...... ... .. . has been refused for the following reasons, namely:
·························································································.
Dated the ................ ... 20 ........... ..
Commissioner PORMP (Rules 50) Whereas an agreement to pay compensation ts said to have been reached between .............................. .......... and .......•....•.•...•. and whereas ................... .
has/have applied for regtstratlon of the agreement under Section 28 of the Workmen·s Compensation Act, 1923, and whereas It appears to me that the said agreement ought not to be registered for the following reasonS', namely:
························································································································ ..... ..... an opportunity will be afforded to you of showing cause on .................... 20 ............ why the said agreement should be registered. If no adequate cause ts shown on that date, registration of the agreement will be refused.
Dated the ................... 20 ........ .
FORM Q (Rules 50) Commissioner Whereas an agreement to pay compensation Is said to have been between ................... and................... ..... and whereas has/have. applied for regtstraUon of the ag;:;~~t under Sec • ···•••· Workmen s Compensatton Act. 1923 and whereas ft appear, to agreement ought not to be regtaten:d for the followtng ...................................................
1'i1f'fiTt ~ fll1fq, 1924 60 TJ<m ~--~~~~-q~~~Wt*'1U ~. ~. *~~f.f:~ -q~~~. ~. ~~ ;;,y~•· lRiilll [~49] ~ alli <ti)~ im ~ 1: ~ 3RI ~ ~ <5Ut ......... .... .... ~················* lfl,l{ J31T cQT l11'T t ~ atli ~ fcti ..... .. ............... ~ ~ ~ ~ 1923~wm2s*aWo~*~*~~~~t1ara:~~~ ;;mu t f.li oW cfiffl ~ ~ ....... ............... 20 ........... cti) fcRR fctillT ~ ~ ~ fct; ~ cf;"{R * -smr c1i1t qt~ om arm1 <ti)~ ;;ml,~~~* 3Nrq-q 11 -..;m iii~ *~~~*~31mPffl{I ~ ...................... 20 ... ...... .. .. .
~ .....................• 20.............. ································· ······· ········ · ···· 1Rli1r({ [~SO] ~ alli % ~ f.li ................... afR ................... % ~ ~ 3Rf ffl q;J ~ ~2 cQ1 ~ t :iR ~ at;q"" 8'A 11 "{{R ~ fcfi' ................... ~ ~ ~ ->11q1'1'4"1, 1923 .... ~ 28 if;~ cfiffl if;~ if;~~~ t, afR ~ a12i <ti) ~~~~~~~tfcfi'ff<liffl'.~.rtuffll~~m ~ .............. ii1 ~~cfiRVI·~ i-·~·~·~···~~·~·~ ~lRT~ 1 al'R~ clRRl'51 .)f ~cfiRVl-;iif ~~~.r~ ~ ~~~.
fcr-lt.li ...................... 20 ............. .
Scanned by CamScanner 61 THE the said . ······ ............ : of showtng cause an opportun1 be aff~:~d agreement should be registcrect. Any on.................... o ............. 11 to make wtth regard to the said agreement rcprcscntauon which you avelf ~••te cause iS then shown. the &grecmcnt shouJd be made on that date. a .. .....- may be rc:glsta'Cd.
Dated the··· ················ 20 ............• POR11 R (Rules 521 ae,llm of ~ts• tbe Year 19 .......... .
Dateol Employer Workman Initials of 5.No Dateol Comm1sslon ~ ~ er ~ I 2 3 4 5 6 .- ··············· Comm1sstoner Reference to orders ~ 7 aaa ~ .. .•••..... ....•.....• 20 ............. .
wq~ [f.rqq 52] ~20 ................ ~~w~~ 4 6