Approved form AF2002-146

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 21
(see r 33)
Application for addition of employer as respondent under the Workers Compensation Act 1951, section 9
[Heading as in Request for arbitration.]
TAKE NOTICE—
That the respondent, C.D.,			alleges that the disease mentioned in the applicant’s particulars filed in this matter was in fact contracted while the applicant [or the deceased worker] was in the employment of			, of		         and not whilst in the employment of C.D. [or as the case may be.]
And C.D.			 	applies for an order that			be joined as respondent in this arbitration, and if necessary for an adjournment of the hearing of the arbitration.
Dated: 						
C.D.
(Signed)
[Or, Solicitor (or, Agent) for the respondent, C.D.]
To the Registrar of the Magistrates Court.

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