Form MC 4 Answer by respondent
Workers Compensation Act 1951
Workers Compensation Rules 2002 (rule 16)
WC no.	
IN THE MAGISTRATES COURT	)	Applicant
	)
OF THE AUSTRALIAN CAPITAL	)
	)	Respondent
TERRITORY	)

Answer by respondent
(for use where respondent is an employer or insurer)

Respondent
(employer details—if more than 1, first respondent, second respondent etc)	name		
	address		ABN 	

Respondent’s insurer(s) (insurer details—if more than 1, list all insurers)	name		claim no. (if known)	
	address		

Respondent’s lawyer	firm name		
	address		
	telephone		fax/email		
	solicitor’s name		reference		

TAKE NOTICE that as to compensation claimed in respect of an injury alleged to have happened on (date) (or, between (date) and (date) when the respondent was insured by (name of insurer):
1.	The respondent denies the claims by the applicant with respect to the liability for and amount of—
	weekly compensation payable to the applicant (Act, pts 4.2 and 4.3)
	medical treatment, damage and other costs (Act, pt 4.5)
	compensation for permanent injuries (Act, pt 4.4.)
	compensation for lump sum where death has resulted from an injury to the worker (Act, s 77 (2) (a))
	weekly compensation payable to dependant who is a child where death has resulted from an injury to the worker (Act, s 77 (2) (b))
	funeral expenses payable where death has resulted from an injury to the worker (Act, s 77 (2) (c))
(Tick each applicable box if liability is denied.  Delete if not applicable)
On the following grounds:
(set out only those grounds which are applicable)
	examples of grounds
1	that the applicant (or, the dead worker) was not a worker to whom the Act applies.
2	that the applicant (or, the dead worker) did not receive any injury on (date) or at all.
3	that although the applicant (or, the dead worker) did receive injury on (date), it was not one which arose out of, or in the course of the applicant’s employment.
4	that the applicant suffered no incapacity for work beyond (date).
5	that the applicant’s incapacity for work beyond (date) did not result from injury arising out of, or in the course of the applicant’s employment on (date).
6	that the injury to the applicant was attributable to the applicant’s serious and wilful misconduct.
7	that notice of the alleged injury was not given to the respondent as required by the Act.
8	that the claim for compensation was not made on the respondent within the time required by the Act.
9	that the injury to the applicant (or, the dead worker) was caused under circumstances creating a legal liability in a person other than the respondent, (name and address of person) to pay damages in relation to the injury, and the applicant (or, the dead worker) has taken proceedings against that person and has recovered damages from the person.
10	in the case of a dead worker, that although the worker received injury arising out of or in the course of employment, the worker’s death did not result from the injury.
2	The respondent admits the following particulars of the application:
3	The respondent denies the following particulars of the application:

Dated
______________________
(solicitor for) respondent