Approved form AF2002-128

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938—Form 4
(see r 13)
Application for arbitration as to compensation payable in relation to expenses of medical attendance and burial, where deceased worker leaves no dependants
E.F.									of [address]		    [description]		       Applicant,					            and
C.D.									of [address]		    [description]					and
G.H.
	of [address]		    [description]		       Respondents.
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 A.B.			resulted from the injury.
2	A.B.			left no dependants within the meaning of the Workers Compensation Act 1951.
3	A question has [or questions have] arisen				 [here state the questions, specifying only those which have arisen; eg]—
	(a)	as to whether A.B.			      was a worker to whom the Workers Compensation Act 1951 applied; or
	(b)	as to the liability of C.D.			  to pay compensation under the Workers Compensation Act 1951 in relation to the reasonable expenses of the medical attendance on and the burial of A.B.			; or
	(c)	as to the amount of compensation payable by C.D.		 under the Workers Compensation Act 1951 in relation to the reasonable expenses of the medical attendance on and the burial of A.B.			; or
	(d)	as to the apportionment and application of the compensation payable by C.D.			           under the Workers Compensation Act 1951 in relation to the reasonable expenses of the medical attendance on and the burial of A.B.
[or as the case may be.]
4	An arbitration under the Workers Compensation Act 1951 is requested between E.F.		and C.D.		     and G.H.			     for the settlement of the question [or questions.]
5	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 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 the nature and cause of injury.

5	Nature of injury to deceased and date of death.
6	Name and address of applicant for arbitration.
7	Character in which applicant applies for arbitration, i.e., whether as legal personal representative of deceased, or as a person to whom expenses in relation to which compensation is payable are due; and if the latter, particulars must be given of the circumstances under which the expenses are claimed to be due to the applicant.
8	Particulars as to any other persons who claim that expenses in relation to which compensation is payable are due to them, and who are therefore made respondents, with their names and addresses.
9	Particulars of amount claimed as compensation, and of how the applicant desires such amount to be apportioned and applied.
10	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.]
11	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.									G.H.
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