Form MC 2 Application for arbitration by dependants or personal representative of dead worker
Workers Compensation Act 1951
Workers Compensation Rules 2002 (rule 10)
WC no.	
IN THE MAGISTRATES COURT	)	Applicant
		)
OF THE AUSTRALIAN CAPITAL	)
		)	Respondent
TERRITORY		)

Application for arbitration by dependants or personal representative of dead worker

Applicant(s)
(dependant’s or personal representative’s details)	full name		
	address		dob	

Respondent
(employer details—if more than 1, first respondent, second respondent etc)	name		
	address		ABN 	

Respondent’s insurer
(insurer details—if more than 1, list all insurers)	name		
	address		ABN 	

Additional respondent(s) (for example, where others claim to be dependants or dispute apportionment between dependants)	name			
	address		

Dead worker	name		
	address			

Applicant’s lawyer	firm name		
	address		
	telephone		fax/email		
	solicitor’s name		reference		

The applicant requests an arbitration.
Nature of application
	Application for arbitration by or on behalf of dependants in relation to liability for and the amount of compensation payable where death has resulted from injury to the worker and the settlement of questions about who are dependants, or the apportionment and application of the compensation.
(Act, pt 4.6 (Compensation for death))
	Application for arbitration about who are dependants or about the amount payable to each dependant where the total amount payable as compensation to the dependants of a dead worker has been agreed or decided. 
(Tick applicable box)
Dated
______________________
(solicitor for) applicant
Notice to Respondent(s)
A copy of this application for arbitration must be given by you to your insurer within 7 days after you are served with the application.
You are liable to have an award for compensation claimed or other order made against you, unless within 28 days after you are served with this application, you file an answer in the registry of the court.
___________________________
Registrar

Particulars
If there is more than 1 respondent employer, particulars for each employer must be set out on separate sheets headed schedule A, etc, each schedule starting with “particulars of application in relation to the first respondent (second respondent, etc)”.
1	(a)	date of injury (if over a period of time, state period as accurately as possible):	(a)	
	(b)	place where the injury happened:	(b)	
	(c)	work that was being done at the time of injury:	(c)	
	(d)	how the injury happened:	(d)	
2	date and cause of death:		
3	particulars of compensation claimed:
	(a)	$_____lump sum—Act, s 77 (2) (a)
(b)	$_____pw—Act, s 77 (b)
(c)	$_____medical treatment, damage and other costs—Act, pt 4.4
(d)	$_____funeral expenses—Act, s 77 (2) (c)
(e)	$______other (specify) 	
4	(a)	was the worker directly employed by the respondent employer?	(a)	
	(b)	if yes, nature of the worker’s employment at the time of injury:	(b)	
	(c)	if no, how is respondent alleged to be liable for compensation?	(c)	
	(d)	if the respondent employer is not the direct employer, nature of work undertaken by the worker:	(d)	
5	if the injury is a disease contracted by gradual process, the names and address of all other employers by whom the worker was employed the nature of which the disease was due:		
6	name, date of birth and relationship to worker of each person alleged to be dependant on the worker and the extent of alleged dependency:		
Note 1	Further particulars may be attached.
Note 2	Particulars must be given of any other facts alleged, failure to give which may take the respondent by surprise.
	death certificate of worker attached
	certified copy of birth certificate of each dependant attached
	medical reports in support of application attached
(Tick applicable boxes)