Form 3.59	Application for arbitration by employer or insurer
Court Procedures Rules 2006
(see r 3907 (Application for arbitration—by employer or insurer))
In the Magistrates Court of the Australian Capital Territory

No WC		of (year) (Court to complete)

(name)
Applicant

(name)
Respondent

Applicant
(employer/insurer details)	full name		
address		ABN	

Respondent
(injured worker’s details)	name		claim no.	
	address		dob	

Applicant’s insurer
(for applicant employer—if more than 1 insurer, list all insurers)	name		
	address		ABN 	

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

The applicant requests an arbitration.
Nature of application
	Application for arbitration about the rejection by the applicant of the respondent’s claim for compensation.
	(Workers Compensation Act, s 132 (Rejecting claims from 1 year)
	Other (state nature of application).
(Tick applicable boxes)
Date:

(signature of applicant or applicant’s solicitor)
(name of applicant or applicant’s solicitor)
Notice to respondent
You may file an answer to this application for arbitration in the Court not later than 28 days after the day the application is served on you (see r 3913 (Application for arbitration—answer by respondent or third-party respondent).
If you do not file an answer within this time, you are liable to have an order made against you.

Particulars
1	(a)	date of injury (if over a period of time, state the period as accurately as possible):	(a)	
	(b)	place where the injury happened:	(b)	
	(c)	how the injury happened:	(c)	
2	nature of injury		
3	particulars of compensation being paid at date of application:	$_____pw 
	
4	(a)	date of commencement of compensation:	(a)	
	(b)	whether by court award or otherwise:	(b)	
5	(a)	total compensation paid to respondent to date of application:
(b)	total medical treatment, damages and other costs paid to or on behalf of respondent to date of application:
		
6	grounds for application		
Note 1	Further particulars may be attached.
Note 2	Particulars must be given of any other facts alleged, failure to give which may take the respondent by surprise.
	medical reports in support of application attached
(Tick box if applicable)