Approved form AF2002-190

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 65
(see r 76)
Application for summons of medical referee as assessor
[Heading as in request for arbitration.]
The applicant [or respondent] applies to the Court to summon a medical referee to sit with it as an assessor on the ground that questions are likely to arise in the determination as to the condition of the applicant or his or her fitness for employment [or as the case may be], and that it is desirable that the Court should have the assistance of a medical referee in the determination of the questions.
Dated:
To the Registrar of the Magistrates Court.
(Signed)
A.B., applicant.
or
Applicant’s solicitor or agent.
The Magistrates Court consents to a medical referee being summoned to sit with it as an assessor.
Magistrate.

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