Approved form AF2002-177

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 52
(see r 57 (10))
Certificate of identity
[to be carefully preserved]
Notice—This Certificate is no Security whatever for a Debt
No. of certificate	                 .
[Heading as in award or memorandum.]
This is to certify that A.B.			     late of [address and description] is entitled to a weekly payment of			   from [name and address of employer] as compensation payable to A.B.			in respect of personal injury arising out of and in the course of his or her employment, such weekly payment to continue during the total or partial incapacity of A.B.			for work.
And that the description of the said A.B.			 and his or her incapacity for work, as certified by the medical referee appointed in this matter, are as follows:
age:
height:
hair:
eyes:
nature of incapacity:
[describe nature of incapacity, as in certificate of medical referee.]
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