Approved form AF2002-131

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938—Form 7
(see r 13 and r 33)

Application for arbitration by or on behalf of dependants of deceased worker whose death has been caused by industrial disease
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			J.K.		        , a medical referee appointed for the purposes of the Workers Compensation Act 1951, certified that A.B.			of			was suffering from				, a disease coming within the Act, section 9, and was thereby disabled from earning full wages at the work at which he or she was employed; and on the			day of			A.B.		      died, his or her death being caused by the disease.
[Or 1.  On the		day of		            A.B.		of		               was under the [give the name of the Act in question], suspended from his or her usual employment on account of his or her having contracted			         , a disease coming within the Workers’ Compensation Act 1951, section 9, and on the			day of			A.B.			     died, his or her death being caused by the disease.
[Or 1.  On the			day of			A.B.			    late of			 died, his or her death being caused by			                         , a disease coming within the Workers Compensation Act 1951, section 9.]
2	The applicant alleges that the disease was due to the nature of the employment of A.B.			in		     [described employment], and that he or she was last employed in such employment within the 12 months before his or her disablement or suspension [or, if the worker died without having obtained a certificate of disablement, or was not at the time of his or her death in receipt of a weekly payment on account of disablement, within the 12 months before his or her death] by C.D.			of		.
3	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 1951 applied; 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 whether the disease was in fact contracted whilst A.B.		was in the employment of C.D.	       ; or
	(d)	as to whether the disease was due to the nature of the employment of A.B.		under C.D.		; or
	(e)	as to whether the death of A.B.			was in fact caused by the disease; or
	(f)	as to the amount of compensation payable by C.D.           to the dependants of A.B. under the Workers Compensation Act 1951 is in relation to the injury caused to them by the death of A.B.		        ; or
	(g)	as to who are dependants of A.B.	                 within the meaning of the Workers Compensation Act 1951; or
	(h)	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.]
4	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].
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 under respondent to which the disease was due.
4	Nature of disease.
5	Date of disablement, and date of death.
6	Earnings of deceased during the 3 years before disablement, if he or she had been so long in the employment of the respondent, 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 respondent.
7	Names and addresses of all other employees by whom deceased was employed in the same employment during the 12 months before the date of disablement.
8	Amount of weekly payments (if any) made to deceased under the Act and of any lump sum paid in redemption of them.
9	Name and address of applicant for arbitration.
10	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.
11	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.
12	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).
13	Particulars of amount claimed as compensation, and of the manner in which the applicant claims to have such amount apportioned and applied.
14	Date of service of statutory notice of disablement.  [A copy of the notice to be annexed.]
15	If notice not served, reason for omission to serve same.
The names and addresses, etc [as in form 2.]

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