Approved form AF2002-126

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938—Form 2
(see r 13)
Application for arbitration by or on behalf of dependants of deceased worker, in relation to the compensation payable in relation to the injury to such dependants, where death has resulted from an injury to the worker, and the settlement of questions as to who are dependants, and the apportionment and application of such compensation
E.F. 
of [address]	[description]	Applicant,
and
C.D.
	of [address]	[description]
and
G.H.
	of [address]	[description]	Respondents.
[or as the case may be; see rule 8.]
1	On the			day of			    personal injury arising out of and in the course of his or her employment was caused to A.B. late of		   deceased, a worker employed by C.D.			[or by 		              a contractor with C.D.			 , for the execution of work undertaken by him or her], and on the			day of 			 the death of the said A.B. resulted from the injury.
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.			      was a worker to whom the Workers Compensation Act 1951applied; or
	(b)	as to the liability of C.D.			  to pay compensation under the Workers Compensation Act 1951 to the dependants of A.B.		             in relation to the injury caused to them by the death of A.B.	            ; or
	(c)	as to the amount of compensation payable by C.D. to the dependants of A.B.			under the Workers Compensation Act 1951 in relation to the injury caused to them by the death of A.B.			; or
	(d)	as to who are dependants of A.B.			   within the meaning of the Workers Compensation Act 1951; or
	(e)	as to the apportionment and application of the compensation payable by C.D.			, to the dependants of A.B.		         in relation to the injury caused to them by the death of A.B.
[or as the case may be.]
3	An arbitration under the Workers Compensation Act 1951 is requested between E.F.			, the legal personal representative of A.B.			acting on behalf of the dependants of A.B.		          , [or between E.F.			, a dependant of A.B.		          ] and C.D.			, and G.H.			      , who claims or may be entitled to claim to be a dependant of A.B.
[or as the case may be; see rule 8.]
for the settlement of the question [or questions].
4	Particulars are appended [or annexed].
Particulars
1	Name and late address of deceased worker.
2	Name, place of business, and nature of business of respondent from whom compensation is claimed.
3	Nature of employment of deceased 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 deceased was then engaged, and nature and cause of injury.
5	Nature of injury to deceased, and date of death.
6	Earnings of deceased during the 3 years before the injury, if he or she had been so long in the employment of the employer by whom he or she was immediately employed, or if the period of his or her employment had been less than the 3 years, particulars of his or her average weekly earnings during the period of his or her actual employment under the said employer.
7	Amount of weekly payments (if any) made to deceased under the Act, and of any lump sum paid in redemption thereof.
8	Name and address of applicant for arbitration.
9	Character in which applicant applies for arbitration, i.e., whether as legal personal representative of deceased or as a dependant, and if as a dependant, particulars showing how he or she is so.
10	Particulars as to dependants of deceased by whom or on whose behalf the application is made, giving their names and addresses and descriptions and occupations (if any), and their relationship to the deceased, and if children, their respective ages, and stating whether they were wholly or partially dependent on the earnings of the deceased at the time of his or her death.
11	Particulars as to any persons claiming or who may be entitled to claim to be dependants, but as to whose claim a question arises, and who are therefore made respondents, with their names, addresses and descriptions and occupations (if any).
12	Particulars of amount claimed as compensation, and of how the applicant claims to have such amount apportioned and applied.
13	Date of service of statutory notice of injury on respondent from whom compensation is claimed, and whether given before deceased voluntarily left the employment in which he or she was injured.  [A copy of the notice to be annexed.]
14	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 names and addresses of the respondents to be served with this application are:
C.D.			of		
G.H.			of
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