Form 3.67	Answer by respondent (injured worker)
Court Procedures Rules 2006
(see r 3913 (Application for arbitration—answer by respondent or third-party respondent))
In the Magistrates Court of the Australian Capital Territory

No WC		of (year) 

(name)
Applicant

(name)
Respondent

Respondent
(injured worker’s details)	name		
	address		Date of birth 	

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

TAKE NOTICE that as to the rejection by the applicant of the respondent’s compensation claimed in relation to an injury alleged to have happened *[on (date)/between (date) and (date)]:
1.	The respondent denies the claims by the applicant in relation to the liability for and amount of—
*	weekly compensation payable to the applicant (WCA, pts 4.2 and 4.3)
*	compensation for permanent injuries (WCA, pt 4.4)
*	medical treatment, damage and other costs (WCA, pt 4.5)
(Tick each applicable box)
Note	WCA means the Workers Compensation Act.
On the following grounds:
(set out only those grounds which are applicable)
	examples of grounds
1	that the respondent was a worker to whom the Workers Compensation Act applies
2	that the respondent received an injury on (date)
3	that the injury to the respondent on (date) arose out of, or in the course of, the respondent’s employment with the applicant
4	that the respondent suffered incapacity for work as a result of the injury arising out of, or in the course of, the respondent’s employment with the applicant on (date)
2.	The respondent admits the following particulars of the application:
	(set out particulars of the application that are admitted)

3.	The respondent denies the following particulars of the application:
	(set out particulars of the application that are denied)

Date:

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

*omit if, or whichever is, inapplicable