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 for 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 as follows:
*1	If the cause of action is based on negligence—
	(a)	time, date, place, circumstances of the negligence:
		(i)	(time and date)
		(ii)	(details of plaintiff’s employment)
		(iii)	(where negligence happened or death/injury suffered)
		(iv)	(circumstances)
	(b)	particulars of the negligence:
(particulars)
*2	If the cause of action is based on the defendant’s vicarious liability:
(a)	(name and address of each person for whose negligence the defendant is vicariously liable)
(b)	(particulars of the claim for vicarious liability)
*3	If the cause of action is based on breach of statutory duty:
(a)	(name and provision of the statute)
(b)	(acts or omissions making up the breach)
4	Injuries and disabilities suffered by the plaintiff:
(a)	(injuries)
(b)	(disabilities)
5	Health professionals who have treated the plaintiff for injuries/disabilities: 
(name and address of each health professional)
*6	Claims for economic loss: 
(a)	(particulars of past economic loss)
(b)	(particulars of future economic loss)
*7	Particulars of employment: 
(a)	(name and address of each of plaintiff’s employers during a reasonable period before plaintiff’s death or injury)
(b)	(name and address of each of plaintiff’s employers since plaintiff’s injury).
*8	The Territory or State that the plaintiff claims is the Territory or State of connection for the Workers Compensation Act 1951, section 182D:
(name of Territory or State)
*9	Other material facts relied on in support of claim:
(particulars)

Date:

(signature of plaintiff or plaintiff’s solicitor)

(name of plaintiff or plaintiff’s solicitor)

*omit if, or whichever is, inapplicable