Form 2.4	Statement of claim—employment death or personal injury 
Court Procedures Rules 2006
(see r 50 (Originating claim—content etc), r 53 (Originating claim— statement of claim employment death and personal injury claims) and r 303 (Third-party notice—content etc))
In the *[Supreme/Magistrates] Court of the Australian Capital Territory

No *[SC/MC]		of (year) (Court to complete)

(name)
Plaintiff

(name)
Defendant

The plaintiff claims damages for *[death/personal injury] in relation to an employer’s negligence.
Details of the claim are as follows:
*(if the cause of action is based on negligence)
	time, date, place, circumstances and acts or omissions making up the negligence:
*(if a claim is made for personal injury)
	injuries and disabilities suffered by the plaintiff:
	the name of each health professional who has treated the plaintiff for the injuries and disabilities:
*(if a claim is made for economic loss)
	nature of claims for past or future economic loss:
	the name and address of each employer of the plaintiff during a reasonable period before and since the acts or omissions making up the 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 claim is based on a breach of statutory duty)
	name and provision of the statute
	acts or omissions making up the breach
*(other material facts relied on in support of claim)

Date:
(signature of plaintiff or plaintiff’s solicitor):
(name of plaintiff or plaintiff’s solicitor)

*omit if, or whichever is, inapplicable