Approved form AF2002-173

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 48
(see r 57 (3))
Application by worker intending to cease to reside in Australia for reference to medical referee
In the Magistrates Court at Canberra.
No. of Matter		.
In the matter of the Workers Compensation Act 1951;
and
In the matter of an agreement [or a decision or an award] recorded in the Court as to the weekly payment to A.B.		of		        by C.D.			of			.
Take Notice, that A.B.			of			       , to whom under an agreement [or a decision or an award] in the this matter recorded in this Court on 					              a weekly payment of 			is payable by C.D. as compensation for personal injury to A.B.			arising out of and in the course of his or her employment, intends to cease to reside in Australia:
And that A.B.			intends to apply to the Registrar on					, at 					, for an order referring to a medical referee the question whether the incapacity of A.B.			   resulting from the injury is likely to be of a permanent nature.
A report of a medical practitioner, setting out the nature of the incapacity of A.B.			resulting from the injury, is annexed.
Dated:
(Signed)
Applicant.
[Or	           Applicant’s solicitor or agent.]
To the Registrar of the Magistrates Court,
and to [the employer].

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