Approved form AF2002-88

made under the
Workers Compensation Act 1951

Workers Compensation Act 1951—Form 1

Australian Capital Territory
Workers Compensation Act 1951
Claim for compensation by incapacitated worker

To: *

I [here write full name] of [here write full postal address] hereby claim compensation under the Workers Compensation Act 1951 in respect of personal injury sustained by me and arising out of and in the course of my employment and declare that, to the best of my knowledge and belief, the following replies to the questions and requests for information are true and correct in every particular:

Questions and Requests for Information	Replies	
In what capacity were you employed at the time of your injury? 
		
State the nature of your injury; also how, when and where it was caused
		
If you are claiming in respect of incapacity arising from an industrial disease—
	(a)	What is nature of the disease?

	(b)	When was it caused?

	(c)	When were you first incapacitated by such disease?
	(d)	What was the nature of your employment and for what period were you engaged thereon?

	(e)	If you have previously suffered from such disease state—
	(i)	The approximate date on which it first manifested itself
	(ii)	The extent to which it interfered with your employment		
Was notice of the accident or incapacity served?

If so, on whom, and on what date?
		
Have you engaged in any employment since the date of your injury or incapacity?   If so, give full particulars

If this claim is made more than six months after the occurrence of the accident or incapacity, give reasons for failure to make the claim within that period

Have you a claim against any person, firm or company for compensation, or for any payment in respect of the injury under any other law in force in the Territory or any other place?		

If you have any living children under the age of 16, or any dependent children between the ages of 16 and 25 who are full-time students, give particulars—

Full names of children	Dates of birth	Extent of dependence on worker at time of injury	

Declared at			on the		day of		20    .

Signature of Declarant

Before me †
‡

* The claim should be addressed to the person, firm or company in or by which the worker was employed at the time of the accident.
† The person before whom this declaration is made should sign here and add the title by which he or she takes the declaration, such as ‘police officer’.
‡ The declaration may be made before any of the following persons:
A postmaster or person in charge of a post office, a magistrate, a justice of the peace, a lawyer, a school head teacher, a police officer, a medical practitioner, a notary public, a commissioner for declarations, a minister of religion, or a member of the Legislative Assembly or the Parliament. 

Endnotes
1	This form was originally in the Workers Compensation Regulations 1946, schedule 1.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from the regulations and became a form approved under the Workers Compensation Act 1951, section 222 (see amdt 1.4383, amdt 1.4391).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).

©  Australian Capital Territory 2002