Sick pay scheme – Form of Undertaking

Form text

In consideration of the (a) advancing to me sums, in accordance with Section A (16) of the Sick Pay Scheme, during my absence from duty due to an accident in which I was involved on the (b) 20xx, I undertake to refund to the (c), from any damages received, the total amount so advanced or such part thereof as the (d) may, having regard to the amount of damages recovered, determine after consultation with myself or my representative.

Signed .............................................

Full Name ..........................................

Address ............................................

Witness ..............................

Date .................................

• (a) insert the name of the Employer
• (b) insert the date of the accident involving the third party
• (c) insert the name of the authority to whom the refund should be made [this may be the same as (a) and (d)]
• (d) insert the name of the Employer

Last updated: 1 September 2015