Release of claim for personal injury upon receipt of lump-sum compensation
[In form of declaration]
___________ Railways, Dr., to ___________
Memorandum : _________ day of_______, 20_____
In full payment, settlement, release and discharge of all claims I now have, or may have, arising from, growing out of, or to grow out of personal injuries, loss of time, pain and suffering, and all loss, damages and expenses suffered by me ________ by reason of an accident on the ________ day of ________ 20_____ at or near the station of ______ and consisting in electric shock and knocked from car to ground, back and hand and side injured at _______ and caused by [state cause of accident]. I have received the sum of Rs._______ and do execute the declaration of release as hereunder:
Declaration:
WHEREAS, I have agreed upon a settlement of all claims against the _______, Railway arising from the circumstances set out in the foregoing memorandum, which is made a part of this agreement, and in said settlement have included all damages sustained by me, those not yet ascertained or developed, if any there shall be, as well as those now known, and also have included and settled and all other causes of action at this date existing in my behalf against said Railway, whether arising upon contract or tort, and whether like or unlike the demand specifically referred to above.
Now, in consideration of the payment to me of _________ , hereby acknowledged and declared to be the full and only consideration moving to me, the receipt of which is hereby acknowledged, I do hereby release and forever discharge the ________ Railways and its their officers, employees, successors and assigns, of and from all debts, suits, causes at action, claims and demands whatsoever, at law or in equity, which I now have, or to which I may hereafter become entitled on account of the circumstances aforesaid including damages not yet ascertained or developed, if any there shall be, as well as those now known, and also of and from all or any other causes or things to this date, whether like or unlike the premises, and whether arising in contract or in tort.
IN WITNESS WHEREOF etc.
[Signature of Claimant]
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