Form MC 10 Application for registration of agreement for compensation
Workers Compensation Act 1951
Workers Compensation Rules 2002 (rule 61)
WC no.	
IN THE MAGISTRATES COURT	)	Applicant
	)
OF THE AUSTRALIAN CAPITAL	)
	)	Respondent
TERRITORY	)

Application for registration of agreement for compensation

Applicant
(injured worker’s details)	full name		
	address		claim no.	
			ABN	

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

Respondent’s insurer
(insurer details—if more than 1, list all insurers)	name		
	address		ABN 	

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

The (applicant/respondent) applies for registration of the following agreement:
The applicant, (name), after receiving independent legal advice about this agreement, AGREES to commute his/her rights to compensation under the Act from the respondent (employer/insurer) (name) on the following terms—
Payment to applicant 
The respondent agrees to pay the applicant the settlement sum of (amount), in addition to payments made to or on behalf of the applicant to (date) by the respondent under the Act, within 28 days of the date of this agreement.
or
The respondent agrees to pay the applicant the sum of (amount) (being 90% of the settlement sum of (amount)) and pay the balance of 10% to the Health Insurance Commission under the Health and Services (Compensation) Act 1995 (Cth), in addition to payments made to or on behalf of the applicant to (date) by the respondent under the Act, within 28 days of the date of this agreement.
Costs
The respondent agrees to pay the applicant’s costs as agreed at (amount) or as taxed in accordance with the Workers Compensation Regulations 2002, regulation 57 (3).
or
The parties agrees to pay their own costs.
Rights commuted by applicant 
	(1)	The applicant agrees to commute his/her rights to compensation under the Act for injuries suffered by the applicant arising out of or in the course of his/her employment with the respondent on (date) or between (date) and (date) as follows:
•	the applicant’s entitlement to weekly compensation under part 4.3 of the Act for total or partial incapacity
•	the applicant’s entitlement to compensation for medical treatment, damages and other costs under part 4.5 of the Act
•	the applicant’s entitlement to compensation for permanent injuries under part 4.4
•	the applicant’s entitlement to compensation apart from this Act (specify)
•	the applicant’s entitlement for any other amount (specify)
delete inapplicable clauses
	(2)	The commutation relates to the following injuries:
(list injuries) 
or
The commutation relates to all injuries suffered by the applicant on (date) or between (date) and (date) arising out of or in the course of his/her employment with the respondent.
Other terms 
	(1)	The applicant undertakes to the respondent to execute a common law release if asked to do so.
	(2)	Other (specify).
Dated 
Signed by the applicant after receiving independent legal advice from (name of solicitor or counsel) about the above agreement before entering into it:
____________________________________
applicant	____________________________________
witness	
Signed (name of solicitor or counsel) who confirms that he or she has provided independent legal advice about the above agreement:
____________________________________
lawyer for applicant

Signed before or on behalf of the respondent:
___________________________________
lawyer for respondent

Registration of agreement
The court registers the above agreement, being satisfied that the applicant received independent legal advice about the agreement before entering into it.
The Court does not consider that the agreement is inaccurate or that the agreed amount of compensation is inadequate.
Date of registration:
_____________________
Registrar

_____________________
Magistrate