Approved form AF2002-125

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938—Form 1
(see r 13)
Application for arbitration by injured worker in relation to the compensation payable to him or her

A.B.									of [address]			[description]		         Applicant,					    and
C.D.									of [address]			[description]		        Respondent.
1	On the			day of			    	       personal injury arising out of and in the course of his or her employment was caused to A.B. a worker employed by C.D.			[or by 			, a contractor with C.D.			for the execution of work undertaken by him or her].
2	A question has [or Questions have] arisen				 [here state the questions, specifying only those which have arisen, e.g.]—
	(a)	as to whether A.B.			         is a worker to whom the Workers Compensation Act 1951 applies; or
	(b)	as to the liability of C.D.			   to pay compensation under the Workers Compensation Act 1951 in relation to the injury; or
	(c)	as to the amount [or duration] of the compensation payable by C.D.		to A.B.			     under the Workers Compensation Act 1951 in relation to the injury.
[or as the case may be.]
3	An arbitration under the Workers Compensation Act 1951 is requested between A.B.			and C.D.			        for the settlement of the said question [or questions].
4	Particulars are appended [or annexed].
Particulars
1	Name and address of applicant.
2	Name, place of business, and nature of business of respondent.
3	Nature of employment of applicant at time of injury, and whether employed under respondent or under a contractor with him or her.  [If employed under a contractor who is not a respondent, name and place of business of contractor to be stated.]
4	Date and place of injury, nature of work on which worker was then engaged, and nature and cause of injury.
5	Nature of injury.
6	Particulars of incapacity for work, whether total or partial, and estimated duration of incapacity.
7	Average weekly earnings during the twelve months previous to the injury, if the applicant had been so long employed under the employer by whom he or she was immediately employed, or if not, during any less period during which he or she has been so employed.
8	Average weekly amount which the applicant is earning or is able to earn in some suitable employment or business after the injury.
9	Payment, allowance or benefit received from employer during the period of incapacity.
10	Amount claimed as compensation.
11	Date of service of statutory notice of injury on respondent, and whether given before worker voluntarily left the employment in which he or she was injured.  [A copy of the notice to be annexed.]
12	If notice not served, reason for omission to serve same.
The names and addresses of the applicant and his or her solicitor or agent are:
Of the applicant,
Of his or her solicitor (or agent),
The name and address of the respondent to be served with his or her application are:
Dated:							

(Signed)	

[Applicant.]

[Or, Applicant’s solicitor.]

[Or, Agent.]

Endnotes
1	This form was originally in the Workers Compensation Rules 1938, schedule 1.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from the rules and became a form approved under the rules, rule 89 (see amdt 1.2805, amdt 1.2807).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).

©  Australian Capital Territory 2002