Approved form AF2002-185

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 61
(see r 75)
Application for reference to medical referee under the Act, schedule 1, paragraph 11
In the matter of a claim for compensation made by A.B.			 of			against C.D.			of		       . 
[or where an arbitration is pending,
In the matter of an Arbitration between
A.B.								              of [address]		         [description]		        Applicant,				  and
C.D.								              of [address]		         [description]		        Respondent.
[or, where application is made after weekly payment has been settled,
In the matter of an agreement [or a decision or award] recorded in the Court as to the weekly payment payable to A.B.		            of	           , by C.D.			, of			.
Application is made to the Court on behalf of the above-named A.B. and C.D. for a reference in this matter to a medical referee under the Workers Compensation Act 1951, schedule 1, paragraph 11 under the following circumstances:
1	On			the			day of		       notice was given by [or on behalf of] A.B.			     to the C.D.				     of personal injury to A.B.			        arising out of and in the course of his or her employment, in relation to which injury A.B.			      claims compensation from C.D.			under the said Act.]
[or, where arbitration is pending,
1	An arbitration under the Act is pending between A.B.			and C.D.			  as to the amount of compensation payable to A.B.			  under the Act in relation to personal injury arising out of and in the course of his or her employment.]
[or, where weekly payment has been settled,
1	Under an agreement [or a decision or award] in this matter, recorded in this Court on 				             , a weekly payment is payable to A.B.			    by C.D.			     as compensation in relation to personal injury to A.B.			arising out of and in the course of his or her employment.]
2	The weekly payment claimed by [or payable to] A.B.		is             .
3	A question has [or questions have] arisen between the said A.B.		             and C.D.			as to the condition [or fitness for employment] of A.B.			[or as to whether [or to what extent] the incapacity of A.B.,			is due to the injury], [or as to the condition] [or fitness for employment] of A.B. 			and as to whether [or to what extent] the incapacity of A.B.			is due to the injury], and no agreement can be come to between C.D.			  and A.B.			with reference to such question [or questions.]
4	A.B.			              has submitted himself or herself for examination by a medical practitioner provided by C.D.			            [or has been examined by a medical practitioner selected by himself or herself] [or if so, A.B.			has submitted himself or herself for examination by a medical practitioner provided by C.D.			  and has also been examined by a medical practitioner selected by himself or herself], and a copy of the report of the practitioner is [or copies of the reports of the practitioners are] annexed to this application.
The applicants request that an order may be made referring the matter to a medical referee for his or her certificate as to the condition of A.B.			     and his or her fitness for employment, specifying, where necessary, the kind of employment for which he or she is fit [or for his or her certificate whether [or to what extent] the incapacity of A.B.			 is due to the injury] [or for his or her certificate as to the condition of A.B.			 and his or her fitness for employment, specifying, where necessary, the kind of employment for which he or she is fit, and as to whether [or to what extent] the incapacity of A.B.			is due to the injury].
Dated:
(Signed)
Applicant.
[or Applicant’s solicitor.]
C.D.
[or Solicitor for C.D.]
To the Registrar of the Magistrates Court.

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