Form wording: I, [full name and address in block capitals] hereby acknowledge that any payments, other than statutory sick pay, which the Employer may make to me during my absence from work as a result of an accident which took place on [ ] are made as a loan (without any admission of liability on the part of the Employer).

I undertake to repay this loan in full from such damages or settlement as I may receive in respect of the said accident immediately on receipt of the same.