Supreme Court Rules 1937—Form 1.5
(see o 2 r 13)
Employment personal injury claim statement to accompany originating application
In the Supreme Court of the Australian Capital Territory

No		of (year)

(name/s)
Plaintiff[s]*

(name/s)
Defendant[s]*
In an originating application dated [date], the plaintiff claims damages for death or bodily injury in relation to an employer’s negligence.
Details of that claim are as follows:
	time, date, place, circumstances and acts or omissions constituting negligence 
	If the claim is based on the defendant’s vicarious liability—*
	particulars of any person for whose negligence the defendant is vicariously liable
	particulars of the claim for vicarious liability
	If the action is based on a breach of statutory duty—*
	particulars of the statutory provision
	acts or omissions constituting the breach
	injuries and disabilities suffered by the plaintiff1
	plaintiff’s health professionals2
	nature of claims for past or future economic loss*
If a claim is made for economic loss—the name and address of each employer of the plaintiff during a reasonable period before and since the acts constituting the negligence*
Date:
Signature of plaintiff*/plaintiff’s solicitor*:
*Strike out where inapplicable.
Note 1	See the Supreme Court Rules 1937, order 2 rule 13 (d).
Note 2	See the Supreme Court Rules 1937, order 2 rule 13 (e).

Endnote
1	This form was originally in the Supreme Court Rules 1937.  Under the Court Procedures Act 2004 A2004-59, pt 8, the form became a form approved under that Act. 

©  Australian Capital Territory 2005