Approved form AF2002-127

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938—Form 3
(see r 13)

Application for arbitration as to who are dependants, or as to the amount payable to each dependant, where the total amount payable as compensation to the dependants of a deceased worker has been agreed or ascertained
E.F.									of [address]			[description]		          Applicant,				     and 
C.D.									of [address]			[description]				and
G.H.									of [address]			[description]				and
J.K.									of [address]			[description]				and
L.M.									of [address]			[description]		         Respondents.	
[or as the case may be; see rule 9.]
1	On the			day of			    personal injury arising out of and in the course of his or her employment was caused to A.B.,			   , late of		, deceased, a worker employed by C.D.,			     [or by 			a contractor with C.D.			   , for the execution of work undertaken by him or her] and on the			day of 		             the death of A.B.				resulted from the injury.
2	The amount of compensation payable by C.D.     to the dependants of A.B.		  under the Workers Compensation Act 1951, in relation to the injury caused to them by the death of A.B.	     has been agreed [or ascertained], but a question has [or questions have] arisen 		       [here state the questions, specifying only those which have arisen; eg]—
	(a)	as to who are dependants of A.B. within the meaning of the Workers Compensation Act 1951, or
	(b)	as to the apportionment and application of the compensation payable to the dependants of A.B.			
[or as the case may be.]
3	An arbitration under the Workers Compensation Act 1951 is requested between E.F.,	, the legal personal representative of A.B.		    acting on behalf of N.O.		    P.R.	 etc, dependants of A.B.		       [or between E.F.	 N.O.		 P.R.		         etc, dependants of A.B.], and C.D.		   and G.H.	              J.K.		     and L.M.		      , who are or claim or may be entitled to claim to be dependants of A.B.		           ], and C.D.		 and G.H.		J.K.		           and L.M.		           who are or claim or may be entitled to claim to be dependants of A.B.
[or as the case may be; see rule 9.]
for the settlement of the question [or questions].
4	Particulars are appended [or annexed].
Particulars
1	Name and late address of deceased worker.
2	Name and place of business of employer by whom compensation has been paid or is payable.
3	Date of injury to deceased, and date of death.
4	Agreed or ascertained amount of compensation to be paid to dependants of deceased.
5	Particulars as to whether the compensation money is still payable by the employer or has been paid by him or her, and if so, to whom, and in whose hands it now is.
6	Character in which the applicant applies for arbitration, i.e., whether as legal personal representative of deceased or as a dependant, and if as a dependant, particulars showing how he or she is so.
7	Particulars as to the dependants or persons claiming to be dependants by whom or on whose behalf the application is made, giving their names and addresses, and descriptions and occupations (if any), and their relationship to the deceased, and if children, their respective ages, and stating whether they were or claim to have been wholly or partially dependent on the earnings of the deceased at the time of his or her death.
8	The like particulars as to any dependants who are made respondents.
Note	If there is a legal personal representative, and he or she is not the applicant, he or she must be made a respondent; see rule 9.
9	Particulars as to any persons claiming or who may be entitled to claim to be dependants, but as to whose claim a question arises, and who are therefore made respondents, with their names, addresses, descriptions, and occupations (if any).
10	Particulars of the manner in which the applicant claims to have the amount of compensation apportioned and applied.
The names and addresses of the applicant and his or her solicitor or agent are:
Of the applicant,
	Of his or her solicitor,
	(Or, Agent.)
The names and addresses of the respondents to be served with this application are:
	C.D.
	G.H.
	J.K.
	L.M.
[or as the case may be.]
Dated:							
(Signed)
Applicant.
[Or,	Applicant’s solicitor.]
[Or,	Agent.]

Endnotes
1	This form was originally in the Workers Compensation Rules 1938, schedule 1.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from the rules and became a form approved under the rules, rule 89 (see amdt 1.2805, amdt 1.2807).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).

©  Australian Capital Territory 2002