Approved form AF2002-129

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938—Form 5
(see r 13)

Application for arbitration in relation to the review, termination, diminution, increase, or redemption of a weekly payment
C.D.,  									of [address]		      [description]		         Applicant,				          and
A.B.									of 
[address]		      [description]
[or as the case may be]
An arbitration under the Workers Compensation Act 1951, is requested between C.D.				and A.B.
[or as the case may be]
in relation to the review and termination [or diminution, or increase, or redemption, as the case may be] of the weekly payment payable to A.B.			 under the Act in relation to personal injury arising out of and in the course of his or her employment.
Particulars are appended [or annexed.]
Particulars
1	Name and address of injured worker.
2	Name and place of business of employer by whom compensation is payable.
3	Date and nature of injury.
4	Date of agreement, decision, or award fixing weekly payment, amount of such payment, and date from which it commenced.
5	Relief sought by applicant, whether termination, diminution, increase, or redemption.
6	Grounds on which termination, diminution, or increase is claimed.
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 name and address of the respondent to be served with this application are:
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