Form 3.68	Answer by respondent (dependants or personal representative of dead 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
(details of dependants or personal representatives—if more than 1, first respondent, second respondent etc)	name		
	address		Date of birth 	

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

Dead worker	name		
	address at date of death		

TAKE NOTICE that as to the rejection by the applicant of the respondent’s compensation claim for compensation in relation to an injury to the dead worker 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—
*	compensation for lump sum where death has resulted from an injury to the worker (WCA, s 77 (2) (a))
*	weekly compensation payable to a dependant who is a child where death has resulted from an injury to the worker (WCA, s 77 (2) (b))
*	funeral expenses payable where death has resulted from an injury to the worker (WCA, s 77 (2) (c))
(Tick each applicable box)
Note	WCA means the Workers Compensation Act.
On the following grounds:
(set out only those grounds which are applicable)
	example of grounds
that the respondent was totally or partially dependant on the worker's earnings on the day of the worker's death or, but for the worker’s incapacity because of the injury, would have been dependant.
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