Approved form AF2002-153

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 28

Information to be supplied where a memorandum of agreement made before ascertainment of compensation for payment of a lump sum by way of compromise and satisfaction, or an agreement as to the redemption of a weekly payment by a lump sum, or as to the amount of compensation payable to a person under any legal disability, or to dependants, is presented for registration
A  In case of agreement with injured worker.
[Heading as in memorandum.]
	(a)	A.B.			named in the memorandum of agreement presented for registration in this matter was at the date of the injury [or disablement or suspension]			years of age.
	(b)	He or she was employed as			    , and his or her average weekly earnings computed in accordance with the Workers Compensation Act 1951 were		            .
	(c)	He or she was injured by			, and the nature of his or her injury was as follows:
	(d)	He or she was totally incapacitated for work for a period of		          , but recovered and was fit to resume his or her ordinary work on					:
[or He or she was and is at present totally incapacitated for work, but is expected to recover and to be fit to resume his or her ordinary work in about 		]:
[or He or she was totally incapacitated for work for a period of		          , and is now partially incapacitated, but such partial incapacity is not likely to be permanent, and he or she is expected to recover and to be fit to resume his or her ordinary work in about 		]:
[or He or she was and is totally incapacitated for work, and such incapacity is likely to be permanent]:
[or He or she was totally incapacitated for work for a period of		           , and is still partially incapacitated, and such partial incapacity is likely to be permanent, but he or she is able to do light work, and it is estimated that he or she is able to earn an average weekly amount of			in some suitable employment or business]:
[or as the case may be].
	(e)	A.B.			received the following payments, allowances, or benefits from his or her employers before the date of the agreement:
[Here state payments made, and where a weekly payment has been made, the amount of such payment, and the period for which it was paid.]
[To be signed in accordance with rule 36 (2).]
Dated:
B.  Where death resulted from the injury or industrial disease.
[Heading as in memorandum.]
	(a)	A.B.			        named in the memorandum of agreement presented for registration in the matter, was at the date of the injury [or disablement or suspension or death]			years of age.
	(b)	He or she was employed as			    , and his or her earnings in the employment of			during the 3 years before the injury in the memorandum mentioned [or his or her average weekly earnings during the period of his or her employment under			] were				.
	(c)	He or she left the following dependants wholly dependent upon his or her earnings, and the following dependants partially dependent:
[Here state dependants, with their relationship to the deceased, and particulars showing how and to what extent they were dependent.]
[Or He or she left no dependants wholly dependent upon his or her earnings, but left the following dependants partially dependent:
[Here state dependants, with their relationship to the deceased, and particulars showing how and to what extent they were dependent.]
	(d)	A.B.			received the following payments, allowances, or benefits from his or her employers after the injury [or disablement or suspension]:
[To be signed in accordance with rule 36 (2).]
Dated:

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