Approved form AF2002-168

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 43
(see r 51)

Præcipe for payment into court under the Act, schedule 1, clause 6 and rule 51, where liability to pay compensation is denied, but the employer is willing to pay a sum in settlement
In the matter of a claim for compensation made by the dependants of A.B.	            late of			, deceased, against C.D.			, of
TAKE NOTICE—
1	That a claim has been made under the Workers Compensation Act 1951, by [or on behalf of] the dependants of A.B.			, late of			   , deceased against C.D.			of			, for compensation relation to the injury caused to such dependants by the death of A.B.			        , who died on 					.
2	The dependants allege that the death of the A.B.			 resulted from personal injury arising out of and in the course of his or her employment sustained by A.B.			on 			        at			   [state address where injury was sustained] while he or she was employed as a worker by C.D.			[or by E.F.	           , a contractor with C.D.			 for the execution of work undertaken by them.]
[or, in the case of industrial disease.]
[2	The dependants allege that the death of A.B.		            was caused by			       , a disease coming within the Workers Compensation Act 1951, section 9, and 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 from his or her usual employment] [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.		.].
3	C.D.			 denies his or her liability to pay compensation under the Workers Compensation Act 1951 to the dependants of A.B.			   , but to avoid litigation is willing to pay the sum of			   in full settlement of all claims to such compensation, and such of the dependants of A.B.		             as are not under disability are willing to accept such sum in settlement.
4	C.D.		of,		[or,		, solicitor or agent for C.D.		, of		] therefore pays into court [when paid in by solicitor or agent, add, at the request and by the authority of C.D.		        ] the sum of			[state sum in letters] being the amount which he or she is willing to pay in full settlement of all claims to compensation in this matter.
5	(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 C.D.		  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 C.D.		  ] were		         .
	(c)	To the best of the knowledge and belief of C.D.		  the persons interested as dependants of A.B.			are		        [state dependants, with their ages and relationship to deceased, so far as known].
6	The grounds on which C.D.			denies his or her liability to pay compensation are 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 paid in, with denial of liability, by C.D. in settlement of the claim of the dependants of A.B. for compensation in respect of an injury resulting in his or her death.’

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