Approved form AF2002-137

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 12
(see r 21)

Notice by respondent admitting liability, and submitting to an award for payment of a weekly sum, or paying money into court, or submitting to an award or paying money into court with a denial of liability
[Heading as in Request for arbitration.]
TAKE NOTICE—
That the respondent, C.D.,			           admits his or her liability to pay compensation in this matter.
And he or she submits to an award for payment by him or her to the applicant, A.B.,			of the weekly sum of			 , such weekly payment to commence from the			day of			    , and to continue during the total or partial incapacity of the said A.B.,			 for work, or until the same shall be ended, diminished, increased, or redeemed in accordance with the provisions of the Workers Compensation Act 1951.
And for payment by him or her to the applicant			  forthwith after the award of the amount of such weekly payments calculated from the			      day of			until the first Friday [or other usual pay day] after the date of the award, and for the payment thereafter of the said sum of			     to the applicant			on Friday [or other usual pay day] in every week.
[Or, And C.D.,			  herewith pays into Court the sum of			in satisfaction of such liability.]
[Or, where liability is denied,
TAKE NOTICE—
That the respondent, C.D.,			 submits [follow from above, down to the words in every week.]
[Or, that the respondent, C.D.,			    herewith pays into Court the sum of			      in satisfaction of the applicant’s claim in this matter.]
And further take notice, that, notwithstanding such submission [or payment] the respondent denies his or her liability.
And further take notice, that the address of the said respondent is as follows:	         (state the address).]
Dated: 					
(Signed)
Respondent, C.D.
[or Respondent’s solicitor.						 
(Or Agent).]
To the Registrar of the Magistrates Court, and				
To the applicant, A.B., and							
To the respondents,
[if any, naming them].

Endnotes
1	This form was originally in the Workers Compensation Rules 1938, schedule 1.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from the rules and became a form approved under the rules, rule 89 (see amdt 1.2805, amdt 1.2807).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).

©  Australian Capital Territory 2002