Form MC 5 Notice by respondent to third party respondent
Workers Compensation Act 1951
Workers Compensation Rules 2002 (rule 29)
WC no.	
IN THE MAGISTRATES COURT	)           Applicant
	)
OF THE AUSTRALIAN CAPITAL	)           Respondent
	)
TERRITORY	)           Third Party Respondent

Notice by respondent to third party respondent

To—

Third party 
respondent	name		
	address		ABN 	
Nature of notice
	the respondent claims to be entitled to be indemnified by you against liability to pay compensation to the applicant (Act, s 13 (Subcontracting)) on the ground that at the time of the injury for which compensation is claimed the applicant was immediately employed by you in the execution of work undertaken by the respondent in relation to which the respondent had contracted with you for execution of the work by or under you 
	the respondent claims to be entitled to contribution from you in relation to compensation claimed by the applicant from the respondent in respect of a disease (Act, s 27 (Compensation for death or incapacity through disease)) on the ground that you employed the worker in employment that caused or contributed to the disease prior to the liability of the respondent arising
•	Other (specify nature of notice)

Dated
______________________
(solicitor for) respondent
Notice to third party respondent
A copy of this notice must be given by you to your insurer within 7 days after you are served with the notice.
You are liable to have an order made against you unless, within 28 days after you are served with this notice, you file an answer in the registry of the court.
___________________________
Registrar
	copy of application for arbitration attached
	copy of respondent’s answer attached
(Tick each applicable box)