Approved form AF2002-89

made under the
Workers Compensation Act 1951

Workers Compensation Act 1951—Form 2

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

To: *

I [here write full name] of [here write full postal address] hereby claim compensation under the Workers Compensation Act 1951 for myself and the children named below in respect of the death of [here write full name of deceased worker] 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 was the abovenamed worker employed at the time of his or her injury?
		
State the nature of such injury; also how, when and where it was caused
		
If the death of the worker was caused by an industrial disease—
	(a)	What was nature of disease?

	(b)	When was it caused?

	(c)	When was he or she first incapacitated by such disease?
	(d)	What was the nature of his or her employment and for what period was he or she engaged thereon?

	(e)	If he or she ever previously suffered from such disease, state—
	(i)	The approximate date on which it first manifested itself 
	(ii)	The extent to which it interfered with his or her employment 

Was notice of the accident or incapacity served?

If so on whom and on what date? 
		
What is your relationship to the deceased worker?
		
Were you dependent upon his or her earnings at the time of his or her death? 
If so, state whether you were wholly dependent 
		
If you were only in part dependent, give full particulars 
		
Was any other person contributing towards your maintenance at the time of his or her death, or did you at that time have any other means of support? 

If so, give full particulars 

Are you in receipt of an Invalid or Old-age Pension? 

If so, give full particulars 

Are you receiving or entitled to receive any payment under any law other than the Workers Compensation Act 1951 in respect of the death of the aforesaid worker? 
If so, give particulars 

Give the names, addresses, and relationships to the worker, of all other persons (except children) known to you, who were dependent upon his or her earnings at the time of his or her death 

If this claim is made more than six months after 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? 

Full names of children of deceased worker	Dates of birth	State whether wholly dependent on earnings of worker at time of his or her death	If not wholly dependent, give full particulars	

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