Approved form AF2002-130

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938—Form 6
(see r 13 and r 33)

Application for arbitration by worker disabled by or suspended on account of having contracted industrial disease coming within section 9

A.B.									of [address]			[description]		         Applicant,					    and
C.D.									of [address]			[description]		         Respondents.
1	On the			day of			E.F.		        , a medical referee appointed for the purposes of the Workers Compensation Act 1951, certified that A.B.			of			was suffering from			, a disease coming within the Act, section 9, and was thereby disabled from earning full wages at the work at which he or she was employed.
[Or 1.  On the			day of			A.B	          of			  was under the [give the name of the Act in question], suspended from his or her usual employment on account of his or her having contracted			            , a disease coming within the Workers Compensation Act 1951, section 9.]
2	A.B.			 alleges that the disease is due to the nature of his or her employment in		  [describe employment], and that he or she was last employed in such employment within the 12 months before to the date of disablement [or suspension] by C.D.			of		.
3	A question has [or questions have] arisen				 [here state the questions, specifying only those which have arisen, e.g.]—
	(a)	as to whether A.B.			         is a worker to whom the Workers Compensation Act 1951 applies; or
	(b)	as to the liability of C.D.			 to pay compensation under the Workers Compensation Act 1951, in relation to the disease [or suspension]; or
	(c)	as to whether the disease was in fact contracted whilst A.B.			was in the employment of C.D.	        ; or
	(d)	as to whether the disease is due to the nature of the employment of A.B.		under C.D.		; or
	(e)	as to the amount [or duration] of the compensation payable by C.D.			to A.B.				 under the Workers Compensation Act 1951, in relation to the disease.
[or as the case may be.]
4	An arbitration under the Workers Compensation Act 1951 is requested between A.B.			and C.D.			for the settlement of the question [or questions].
5	Particulars are appended [or annexed.]
Particulars
1	Name and address of applicant.
2	Name, place of business, and nature of business of respondent.
3	Nature of employment of applicant under respondent to which the disease was due.
4	Nature of disease.
5	Date of disablement or suspension.
6	Names and addresses of all other employers by whom applicant was employed in the same employment during the 12 months before the date of disablement or suspension.
7	Particulars of incapacity for work, whether total or partial, and estimated duration of incapacity.
8	Average weekly earnings during the 12 months before the date of disablement or suspension, if the applicant has been so long employed under respondent, or if not, during any less period during which he or she has been so employed.
9	Average weekly amount which the applicant is earning or is able to earn in some suitable employment or business.
10	Payment, allowance, or benefit received from employer during period of incapacity.
11	Amount claimed as compensation.
12	Date of service of statutory notice of disablement or suspension on respondent.  [A copy of the notice to be annexed.]
13	If notice not served, reason for omission to serve same.
The names and addresses etc [as in form 1.]

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