Approved form AF2002-167

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 42
(see r 50)
Præcipe for payment into court under the Act, schedule 1, clause 6 and rule 50, where there is no dispute as to the liability to pay compensation, but the amount payable has not been ascertained or decided by a committee or by arbitration or agreement
In the matter of an injury to A.B.			, late of		        which resulted in the death of A.B.
TAKE NOTICE—
1	That 					    personal injury arising out of and in the course of his or her employment was caused at 		     [state address where injury was sustained] to A.B.			, late of		                   deceased, a worker employed by		, [or by		, a contractor with		         for the execution of work undertaken by them], and on 				 the death of A.B. resulted from the injury.
[Or in the case of industrial disease.
TAKE NOTICE—
1	That on 						E.F.		              , a medical referee certified that A.B.			             of		  was suffering from			   , a disease coming within the Workers Compensation Act 1951, section 9, and was thereby disabled from earning full wages at the work at which he or she was employed; and on 				A.B.			died, his or her death being caused by the disease.]
[Or, That on 							        A.B.			, of			was under the [give the short title 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 						A.B.			died, his or her death being caused by the disease.]
[Or, That on 						        A.B.			late of			 died, his or her death being caused by			                      , a disease coming within the Workers Compensation Act 1951, section 9;
And that the dependants of A.B.			             allege that the disease was due to the nature of the employment of A.B.		 in			[describe 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	       .]
2	There is no dispute as to the liability of 				 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.		                 , but the amount payable as compensation has not been ascertained or decided either by a committee or by arbitration or by agreement.
3				of			[or		       , solicitor or agent for the said			of			 ] therefore pays into court [when paid by solicitor or agent, add, at the request and by the authority of				       ] the sum of [state sum in letters] being the amount admitted by 				               to be payable by him or her as compensation in the this matter.
4	(a)	A.B.			   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 [or disablement or suspension or death] or his or her average weekly earnings during the period of his or her employment under				] were		                 .
5	To the best of the knowledge and belief of 			         the persons interested in the sum as dependants of A.B.		 are	       [state dependants, with their ages and relationship to deceased worker, and places of residence, as far as known.]
6	The amount admitted by 				                 to be payable as compensation has been arrived at as follows:
Dated:
(Signed)
[or solicitor or agent for	               .]
To the Registrar of the Magistrates Court.
Note	A receipt for the money paid in with this præcipe is to be given on the usual form used by the Registrar, with the following addition:— ‘being the amount admitted by C.D. to be payable by him or her as compensation in relation to an injury resulting in the death of A.B.’

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