Approved form AF2002-141

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 16
(see r 22 and r 23)

Notice by respondent to third parties
[Heading as in Request for arbitration.]
To			, of			(address and description).
TAKE NOTICE that A.B.		of		            , has filed a request for arbitration (a copy of which is annexed) as to the amount of compensation payable by the respondent, C.D.		, to A.B.		 in relation to personal injury to A.B.			arising out of and in the course of his or her employment.
(Or, That E.F.		of		     has filed a request for arbitration (a copy of which is annexed) in relation to the compensation payable to the dependants of A.B.		deceased, in relation to the injury caused to the said dependants by the death of A.B.		       which resulted from injury to A.B.		      arising out of and in the course of his or her employment.
(or as the case may be; see forms of request for arbitration.)
The respondent, C.D.			, claims to be indemnified by you against his or her liability to pay such compensation, on the ground that at the time of the injury in relation to which compensation is claimed A.B.			            was not immediately employed by C.D.			, but was employed by you in the execution of work undertaken by C.D.			       , in relation to which C.D.		had contracted with you for the execution of the work by or under you.
(Or, on the ground that the injury for which compensation is claimed was caused under circumstances creating a legal liability on your part to pay damages in relation to the injury.)
(Or as the case may be.)
(Or, in case of industrial disease, The respondent, C.D.			   , claims to be entitled to contribution from you in relation to the compensation claimed from him or her, on the ground that the disease mentioned in the applicant’s particulars was of such a nature as to be contracted by a gradual process, and that A.B.			           was employed by you during the 12 months before the date of disablement or suspension in the employment to the nature of which the disease was due.)
And take notice, that if you wish to dispute the applicant’s claim as against the respondent C.D.			, or your liability to the respondent, you must appear before the Court at the time and place mentioned in the notice, a copy of which is annexed.
In default of your so appearing, you will be deemed to admit the validity of any award made in the said arbitration as to any matter which the Court has jurisdiction to decide in such arbitration as between the applicant and the respondent, C.D.			 , whether such award is made by consent or otherwise, and your own liability to indemnify the respondent C.D.,			(or to contribute as above mentioned).
Dated: 						
(Signed)
C.D.
(Or,
Solicitor or agent for the respondent, C.D.)

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