Form 3.57	Application for arbitration by injured worker
Court Procedures Rules 2006
(see r 3905 (Application for arbitration—by worker))
In the Magistrates Court of the Australian Capital Territory

No WC		of (year) (Court to complete)

(name)
Applicant

(name)
Respondent

Applicant(s)
(injured worker’s details)	full name		
	address		dob	

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

Respondent’s insurer(s) (insurer details—if more than 1, list all insurers)	name		claim no. (if known)	
	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 injured worker in relation to the respondent’s liability for and amount of weekly compensation payable to the applicant
(Workers Compensation Act, pt 4.2 (Compensation for personal injury) and pt 4.3 (Weekly compensation))
	application for arbitration by injured worker in relation to the respondent’s liability for and amount of compensation for permanent injuries
(Workers Compensation Act, pt 4.4 (Compensation for permanent injuries))
	application for arbitration by injured worker in relation to the respondent’s liability for and amount of medical treatment, damage and other costs
(Workers Compensation Act, pt 4.5 (Compensation for medical treatment, damage and other costs))
	Other (specify nature of application)
(Tick each applicable box)
Date:

(signature of applicant or applicant’s solicitor)
(name of applicant or applicant’s solicitor)
Notice to respondent(s)
You must give a copy of this application for arbitration to your insurer not later than 7 days after the day you are served with the application.
You may file an answer to this application for arbitration in the Court not later than 28 days after the day the application is served on you (see r 3913 (Application for arbitration—answer by respondent or third-party respondent).
If you do not file an answer within this time, you are liable to have an award for compensation claimed or other order made against you.

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 the 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	(a)	nature of injury:	(a)	
	(b)	incapacity for work (state whether total, partial or partial claimed as total and the periods for each):	(b)	
3	particulars of compensation claimed:
	(a)	$___pw from __/__/__ to __/__/__(or continuing)
(b)	$____ lump sum in respect of loss (permanent injury—WCA, pt 4.4)
(c)	$_____ medical treatment, damage and other costs—WCA, pt 4.5
(d)	$_____ other (specify) 
	
4	(a)	date of notice of injury:	(a)	
	(b)	date of claim for compensation:	(b)	
	(c)	reason for failure to give any notice:	(c)	
5	(a)	was the applicant directly employed by the respondent employer?

	(a)	

5	(b)	if yes, nature of the applicant’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 applicant:	(d)	
6	(a)	applicant’s average pre-incapacity weekly earnings (WCA, s 21 or 22):	(a)	
	(b)	pre-incapacity floor (WCA, s 39 (5)):	(b)	
	(c)	applicant’s average pre-incapacity weekly hours (WCA, s 23 and 24):	(c)	
	(d)	applicant’s average weekly amount during periods claimed (WCA, s 40):	(d)	
7	payment, allowance or benefit received from the employer 
during the period of incapacity and the date on which the payment ceased:		
8	if the injury is a disease contracted by a gradual process, the names and address of all other employers by whom the applicant was employed the nature of which the disease was due:		
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.
Note 3	WCA means the Workers Compensation Act.
	medical reports in support of the application attached
	copy of injury notice (Workers Compensation Act, s 123) attached
(Tick each applicable box)