Form 3.58	Application for arbitration by dependants or personal representative of deceased worker
Court Procedures Rules 2006
(see r 3906 (Application for arbitration—by dependant or estate of deceased worker))
In the Magistrates Court of the Australian Capital Territory

No WC		of (year) (Court to complete)

(name)
Applicant

(name)
Respondent

Applicant(s)
(dependant’s or personal representative’s details)	full name		
	address		dob	

Respondent
(employer details—if more than 1, first respondent, second respondent etc)	name		
	address		ABN 	

Respondent’s insurer
(insurer details—if more than 1, list all insurers)	name		
	address		ABN 	

Additional respondent(s) (for example, where others claim to be dependants or dispute apportionment between dependants)	name			
	address		

Deceased worker	name		
	address			

Applicant’s lawyer	firm name		
	address		
	telephone		fax/email		
	solicitor’s name		reference		
The applicant requests an arbitration.
Nature of application
	Application for arbitration by or on behalf of dependants in relation to liability for and the amount of compensation payable where death has resulted from injury to the worker and the settlement of questions about who are dependants, or the apportionment and application of the compensation.
(Workers Compensation Act, pt 4.6 (Compensation for death))
	Application for arbitration about who are dependants or about the amount payable to each dependant where the total amount payable as compensation to the dependants of a deceased worker has been agreed or decided. 
(Tick applicable box)
Date:

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

Notice to respondent(s)
You must give a copy of this application for arbitration to your insurer not later than 7 days after the day you are served with the application.
You may file an answer to this application for arbitration in the Court not later than 28 days after the day the application is served on you (see r 3913 (Application for arbitration—answer by respondent or third-party respondent).
If you do not file an answer within this time, you are liable to have an award for compensation claimed or other order made against you.

Registrar

Particulars
If there is more than 1 respondent employer, particulars for each employer must be set out on separate sheets headed schedule A, etc, each schedule starting with “particulars of application in relation to the first respondent (second respondent, etc)”.
1	(a)	date of injury (if over a period of time, state period as accurately as possible):	(a)	
	(b)	place where the injury happened:	(b)	
	(c)	work that was being done at the time of injury:	(c)	
	(d)	how the injury happened:	(d)	
2	date and cause of death:		
3	particulars of compensation claimed:
	(a)	$_____lump sum—WCA, s 77 (2) (a)
(b)	$_____pw—WCA, s 77 (b)
(c)	$_____medical treatment, damage and other costs—WCA, pt 4.4
(d)	$_____funeral expenses—WCA, s 77 (2) (c)
(e)	$______other (specify) 	
4	(a)	was the worker directly employed by the respondent employer?	(a)	
	(b)	if yes, nature of the worker’s employment at the time of injury:	(b)	
	(c)	if no, how is respondent alleged to be liable for compensation?	(c)	
	(d)	if the respondent employer is not the direct employer, nature of work undertaken by the worker:	(d)	
5	if the injury is a disease contracted by gradual process, the names and address of all other employers by whom the worker was employed the nature of which the disease was due:		
6	name, date of birth and relationship to worker of each person alleged to be dependant on the worker and the extent of alleged dependency:		
Note 1	Further particulars may be attached.
Note 2	Particulars must be given of any other facts alleged, failure to give which may take the respondent by surprise.
Note 3	WCA means the Workers Compensation Act.

	death certificate of worker attached
	certified copy of birth certificate of each dependant attached
	medical reports in support of application attached
(Tick applicable boxes)