Form MC 3 Application for arbitration by employer or insurer
Workers Compensation Act 1951
Workers Compensation Rule 2002 (rule 11)
WC no.	
IN THE MAGISTRATES COURT	)	Applicant
		)
OF THE AUSTRALIAN CAPITAL	)
		)	Respondent
TERRITORY		)

Application for arbitration by employer or insurer

Applicant
(employer/insurer details)	full name		
address		ABN	

Respondent
(injured worker’s details	name		claim no.	
	address		dob	

Applicant’s insurer
(for applicant employer (if more than 1 insurer, list all insurers))	name		
	address		ABN 	

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

The applicant requests an arbitration.
Nature of application
	Application for arbitration about the rejection by the applicant of the respondent’s claim for compensation.
(Act, s 132 (Rejecting claims from 1 year)
	Other (specify nature of application).
(Tick applicable boxes)
Dated
______________________
(solicitor for) applicant
Notice to respondent
You are liable to have an 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
1	(a)	date of injury (if over a period of time, state the period as accurately as possible):	(a)	
	(b)	place where the injury happened:	(b)	
	(c)	how the injury happened:	(c)	
2	nature of injury		
3	particulars of compensation being paid at date of application:	$_____pw 
	
4	(a)	date of commencement of compensation:	(a)	
	(b)	whether by court award or otherwise:	(b)	
5	(a)	total compensation paid to respondent to date of application:
(b)	total medical treatment, damages and other costs paid to or on behalf of respondent to date of application:
		
6	grounds for application		
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.
	medical reports in support of application attached
(Tick box if applicable)