Form 3.66	Application for registration of agreement for compensation
Court Procedures Rules 2006
(see r 3966 (Registered agreement—application for registration))
In the Magistrates Court of the Australian Capital Territory

No WC		of (year)

(name)
Applicant

(name)
Respondent

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 Workers Compensation Act from the respondent (name of employer/insurer) 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 Workers Compensation Act, not later than 28 days after 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 Medicare Australia under the Health and Other Services (Compensation) Act 1995 (Cwlth), in addition to payments made to or on behalf of the applicant to (date) by the respondent under the Workers Compensation Act, not later than 28 days after the date of this agreement.
Costs
	*The respondent agrees to pay the applicant’s costs *[agreed at (amount)/assessed in accordance with rule 3968 (4)].
or
	*The parties agree to pay their own costs.
Rights commuted by applicant 
(1)	The applicant agrees to commute *[his/her] rights to compensation under the Workers Compensation 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 permanent injuries under part 4.4
	*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 apart from this Act (state)
	*the applicant’s entitlement for any other amount (state)
(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)	(state any other term).
Date: 
Signed by the applicant after receiving independent legal advice from (name of applicant’s solicitor or counsel) about the above agreement before entering into it:

(signature of applicant)
(name of applicant)

(signature of witness)
(name of witness)

I, (name of applicant’s solicitor or counsel), confirm that I have provided independent legal advice about the above agreement and, based on my experience of (number of years) practice in workers compensation proceedings and my knowledge of this claim and the issues, I am of the opinion that the agreed amount of compensation is not manifestly inadequate.

(signature of applicant’s solicitor or counsel)
(name of applicant’s solicitor or counsel)

(signature of respondent’s solicitor or counsel)
(name of respondent’s solicitor or  counsel)

*omit if, or whichever is, inapplicable

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 manifestly inadequate.
Date of registration:

Registrar

Magistrate