Work Health Court Rules 1999

The Work Health Court Rules (1987, No. 18 and 1990, No. 7) are repealed.

Schedule Forms

rule 2.05(1)

FORM 2A

rule 2.06(3)

INDEX OF DOCUMENTS

[Heading as in Form 5A]

The documents listed below and attached to this index are filed by

[identify party]:

(Give brief description, in numerical order, of each document filed.)

1.

2.

(Continue as necessary.)

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared and filed by [name, address, telephone number, facsimile number and reference number of party or party's legal practitioner]. (If the legal practitioner is acting as the agent of another practitioner, also insert the name, address, telephone, facsimile and reference numbers of the principal.)

(NOTE

TO PARTY FILING DOCUMENTS: Number the documents consecutively at the top of each first page and attach securely to this index in numerical order.)

FORM 3A

rule 3.07(2)

* NOTICE OF DISCONTINUANCE

* NOTICE OF WITHDRAWAL

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

AND

TO THE COURT

The

[identify party] gives notice that:

* this application is discontinued.

* the counterclaim made in this proceeding is discontinued.

* the appearance filed in this proceeding is withdrawn.

* the notice of defence filed in this proceeding is withdrawn.

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Do not ignore this notice. If you do not understand this notice or need help contact a Registrar of the Work Health Court, a legal practitioner or your local legal aid office.

Prepared and filed by [footer as in Form 2A]

* Delete if inapplicable.

NORTHERN TERRITORY OF AUSTRALIA

Return to Work Act 1986

FORM 5A

rule 5.02(1)

APPLICATION TO THE WORK HEALTH COURT

IN

THE WORK HEALTH Claim No.

COURT

AT [VENUE]

BETWEEN [FULL

NAME] * Worker/Applicant *

and

[FULL

NAME] * Employer/Respondent *

TO

THE * EMPLOYER/RESPONDENT *

AND

THE COURT

This application is made to the Work Health Court for the following: (tick the appropriate box)

The

* employer/respondent * MUST, NOT LATER THAN 14 DAYS

AFTER BEING SERVED with this application:

file an appearance, in accordance with Form 5C, with a Registrar of the Work Health Court at [address]; and

serve a copy of the appearance on the party making this application.

IF an appearance is not filed and served within the time specified above, the * worker/applicant * MAY OBTAIN DEFAULT

JUDGMENT.

Dated: [e.g.

1 April 1999]

[signature of worker/applicant

or legal practitioner]

Filed:

Registrar

Do not ignore this application. If you do not understand this application or need help contact a Registrar of the Work Health

Court, a legal practitioner or your local legal aid office.

1. This application was filed:

* by the * worker/applicant * in person.

* for the worker by [name of person representing worker under section 98 of Act] of [address]. (Address may include person's telephone number and facsimile number (if any).)

* for the * worker/applicant * by [name of that party's legal practitioner] of [name of firm], legal practitioner(s), of [business address in Australia including telephone, facsimile and reference numbers]. (If the legal practitioner is the agent of another legal practitioner, also insert the name of the principal's firm and business address including telephone, facsimile and reference numbers.)

2. The address of the * worker/applicant * is –

(Address may include party's telephone number and facsimile number (if any).)

3. The address for service of the * worker/applicant * is –

(If that party applies in person insert the address as in 2. If that party is represented by a legal practitioner or a person under section 98 of the Act, insert the address as in 1.)

4. The address of the * employer/respondent * is:

(NOTES

TO APPLICANT:

1. An application under section 62(2) of the Return to Work Act 1986 is to be accompanied by a list of the names and addresses of all other persons who, to the best of the applicant's knowledge, were dependants of the deceased worker at the time of death.

2. Unless the Court orders otherwise, an application referred to in section 104(3) of the Return to Work Act 1986 is to be accompanied by copies of the following documents (as applicable):

See rule 2.06(3) on how to file accompanying documents.

the worker's claim form and medical certificates referred to in section 82 of the Return to Work Act 1986;

notifications of decisions and statements under section 85 of the Return to Work Act 1986;

applications and decisions made under section 86 of the

Return to Work Act 1986;

notices and statements given under section 69 of the

Return to Work Act 1986;

all medical reports in the worker's possession, whether or not they support the worker's claim;

the certificate issued by the mediator under section 103J of the Return to Work Act 1986.

3. An application in respect of an interim determination under section 107 of the Return to Work Act 1986 is to be made by interlocutory application (Form 6A and affidavit).

4. A sealed copy of this application and, if applicable, the documents filed with the application are to be served on each other party. You must file sufficient copies to allow for service of sealed copies.)

*

Delete if inapplicable.

FORM 5B

rule 5.04(2)

AFFIDAVIT OF SERVICE

[Heading as in Form 5A]

NAME

OF DEPONENT:

DATE

AFFIDAVIT MADE:

I,

[full name of deponent], [occupation or description], of [deponent's address], make oath and say that:

1. At [time] on [day] the [date] of [month]

[year] I served the Form 5A application filed in this proceeding on [filing date] personally on the

* employer/respondent *, [full name of party served], at [address where served].

2. Personal service was effected as follows:

[details]

*3. I identified the * employer/respondent * as follows:

[details]

Made at [place] on

[date]

________________

By

[signature of deponent]

Witnessed by

Signature______________________________________________________

Justice of the peace / commissioner for oaths

Commissioner for Affidavits or Declarations or Notary Public (for service under Service and Execution of Process Act 1992 (Cth))

Name________________________________________________________

Address or phone no. __________________________________________

Prepared and filed by [footer as in Form 2A]

*

Delete if inapplicable.

FORM 5C

rule 5.06(1)

APPEARANCE

[Heading as in Form 5A]

TO

THE * WORKER/APPLICANT *

AND

TO THE COURT

In response to the application dated [e.g. 2 November 1998], I state that:

1. The full name and address of the * employer/ respondent * is:

*2. The name and address of the * employer's/respondent's * legal practitioner is – [name of party's legal practitioner] of [name of firm], legal practitioner(s) of

[business address in Australia including telephone, facsimile and reference numbers]. (If the legal practitioner is the agent of another legal practitioner, also insert the name of the principal's firm and business address including telephone, facsimile and reference numbers.)

3. The * employer's/respondent's * address for service is –

(If the party defends in person insert the address as in 1. If the party is legally represented insert the address as in 2.)

*4. The facts stated by the * worker/applicant * on the original claim form are alleged to be inaccurate or incomplete for the following reasons: (See note.)

*5. The employer has the following claim against the worker:

[brief statement of claim]

*6. The respondent claims, as a dependant of the deceased worker, to be entitled to a proportion of the amount payable under section 62 of the Return to Work Act 1986.

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

*

Delete if inapplicable.

(NOTE

TO EMPLOYER: An employer's appearance in respect of an application by a worker is to be accompanied by all hospital reports and medical reports in the employer's possession relating to the worker's claim, whether or not they support the employer's allegations in item 4. See rule 2.06(3) on how to file accompanying documents.)

FORM 6A

rule 6.03(a)

INTERLOCUTORY APPLICATION

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

You are ordered to attend before the Work Health Court for the hearing of an application by the [identify party] for [description of order sought].

This application is made in pursuance of rule [no.]

The application will be heard by the Court at [address of Court] at a.m./p.m. on or as soon afterwards as the business of the Court allows.

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Registrar

Do not ignore this notice. If you do not understand this notice or need help contact a Registrar of the Work Health Court, a legal practitioner or your local legal aid office.

Prepared and filed by [footer as in Form 2A]

(NOTES

TO APPLICANT:

1. This application may be supported by an affidavit.

2. A sealed copy of this application and, if applicable, the affidavit are to be served on each other party. You must file sufficient copies to allow for service of sealed copies.)

FORM 6B

rule 6.09(1)(a)

NOTICE OF CONSENT TO INTERLOCUTORY ORDER

[Heading as in Form 5A]

TO

THE COURT

The

[identify consenting party] consents to the Court making an interlocutory order that:

1. [terms of order]

2.

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 7A

rule 7.01(1)

NOTICE OF DIRECTIONS CONFERENCE

[Heading as in Form 5A]

A directions conference has been listed to take place at the Work

Health Court at [address] at a.m./p.m.

on or as soon afterwards as the business of the Court allows.

All parties must attend the directions conference and be prepared to discuss all issues.

An individual must attend the conference personally.

An officer or employee of a corporation must be authorised in writing by the corporation to attend the conference and to settle the matter if possible. A partner of a firm must have the unfettered written authority of all the other partners to attend the conference and to settle the matter if possible.

Attendance at the conference on behalf of the Territory is to be by an employee (as defined in the Public Sector Employment and Management

Act 1993) of the Agency for which the Territory is conducting the proceeding, who is authorised in writing by the Chief

Executive Officer of that Agency to attend the conference and to settle the matter if possible.

An employer who is insured must be accompanied by the insurer's representative.

A party who is legally represented may be accompanied by the legal representative who must be fully instructed about the conduct of the proceeding and the options for settlement.

If the person making the application fails to attend, the Court may strike out the claim. If the person who filed the appearance fails to attend, the Court may give the person making the application leave to proceed as if an appearance had not been filed or may make other orders it considers appropriate. A party who is unable to attend should contact a Registrar of the Work Health Court. A Registrar may give you leave to attend by communication link. The Court may dispense with the requirement of attendance in person (either physically or by communication link) in special circumstances.

Dated:

Registrar

Do not ignore this notice. If you do not understand this notice or need help contact a Registrar of the Work Health Court, a legal practitioner or your local legal aid office.

FORM 7B

rule 7.04(4)(a)(ii)

SCHEDULING ORDER

[Heading as in Form 5A]

At a directions conference held at the Work Health Court at [place] at [time] on [date]:

1. The following persons attended:

(List parties or representatives.)

2. The following details were given by the parties:

(List details, in relation to each party, of matters referred to in rule 7.04.)

3. The following undertakings were given/admissions made:

(List each undertaking/admission and name of party or party's legal practitioner giving undertaking/making admission.)

4. The

Court made the following orders:

(List orders made.)

Dated:

Registrar

FORM 7C

rule 7.09

CASE MANAGEMENT STATEMENT

[Heading as in Form 5A]

(Comments to be as brief as possible.)

Dated:

[e.g. 1 April 1999] Dated: [e.g. 1 April 1999]

Filed:

Prepared and filed by [footer as in Form 2A]

*

Delete if inapplicable.

FORM 9A

rule 9.01(1)

STATEMENT OF CLAIM

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

AND

TO THE COURT

THE

[IDENTIFY PARTY MAKING THE CLAIM] CLAIMS

[concise statement of nature of claim], particulars of which are set out below, and seeks [concise statement of compensation or relief sought]

PARTICULARS OF CLAIM

(Refer to notes.)

Dated:

[e.g. 1 April 1999]

[signature of party or

legal practitioner]

Filed:

Registrar

Prepared and filed by [footer as in Form 2A]

(NOTES

TO PARTY MAKING CLAIM:

1. You must insert all the material allegations of fact (but not the evidence) on which you rely in making the claim. These are to be set out clearly and concisely in summary form in consecutively numbered paragraphs. Each paragraph is to refer to a separate allegation (so far as practicable). The allegations are to be expressed in plain

non-technical language except to the extent required by the nature of the claim. Refer to Part 8 for additional rules that may be relevant to these pleadings.

2. If you are a worker claiming compensation for an injury or disease, the particulars of claim are to contain clear and concise details of the following (as applicable):

worker's date of birth and occupation;

date when and workplace where injury occurred or disease contracted;

nature of injury or disease;

manner in which injury occurred or disease contracted;

nature of disability suffered as result of injury or disease;

the worker's normal weekly earnings at date injury occurred or disease contracted;

dates of periods for which compensation payments claimed;

amount claimed for permanent impairment and nature of permanent impairment;

amount claimed for hospital, medical, surgical or rehabilitation treatment and nature of treatment.

3. If your Form 5A application was made under section 62(2) of the

Return to Work Act 1986, the statement of claim is to contain clear and concise details of the following:

deceased worker's full name, address, occupation and date of birth;

employer's full name and address;

date when and workplace where injury occurred or disease contracted;

date of death;

name and address (if known) of each dependant wholly or partially dependent on deceased worker at date of death and relationship to deceased worker.

4. A sealed copy of this statement of claim is to be served on each other party. You must file sufficient copies to allow for service of sealed copies.)

FORM 9B

rule 9.04(1)

NOTICE OF DEFENCE

[Heading as in Form 5A]

TO

[IDENTIFY PARTY]

AND

TO THE COURT

THE

DEFENCE OF THE [IDENTIFY PARTY DEFENDING THE CLAIM]

IS [concise statement of defence(s) relied on]

PARTICULARS OF DEFENCE

(Refer to notes.)

* COUNTERCLAIM

(Rule 9.05)

* THE

[IDENTIFY PARTY MAKING COUNTERCLAIM] CLAIMS

[concise statement of the nature of the claim] particulars of which are set out below, and seeks [statement of relief or remedy sought]

* PARTICULARS OF CLAIM

(Refer to notes 1 and 5 only.)

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Registrar

Prepared and filed by [footer as in Form 2A]

* Delete if inapplicable.

(NOTES

TO PARTY DEFENDING CLAIM:

1. You must insert all the material allegations of fact (but not the evidence) on which you rely in defending the claim and making the counterclaim (if applicable). These are to be set out clearly and concisely in summary form in consecutively numbered paragraphs. Each paragraph is to refer to a separate allegation (so far as practicable). The allegations are to be expressed in plain English and non-technical language except to the extent required by the nature of the defence or counterclaim.

2. You must plead specifically a fact or matter that:

you allege makes a claim not maintainable; or

raises a question of fact that does not arise out of the statement of claim.

3. An allegation in the statement of claim will be taken as admitted unless you deny the allegation specifically or by necessary implication or state that the allegation is not admitted. If you specifically deny an allegation, you must state what facts you rely on as the basis of the denial.

4. If you intend to prove facts that are different from those in the statement of claim, you must:

specifically deny those facts or state that those facts are not admitted; and

plead the facts you intends to prove.

5. Refer to Part 8 for additional rules that may be relevant to these pleadings.

6. If this notice contains a counterclaim, you must file sufficient copies to allow for service of sealed copies. If this notice does not contain a counterclaim, it need not be sealed and one copy only is to be filed.)

FORM 10A

rule 10.04(2)

CONSENT TO BE LITIGATION GUARDIAN

[Heading as in Form 5A]

To the COURT

I,

[full name of litigation guardian] of [address] have consented to my appointment as the litigation guardian of [name of person under disability].

The above-named is a person under a disability for the following reason(s):

I declare that I have no interest in this proceeding that is adverse to the interest of the person under a disability named above.

Dated: [e.g.

1 April 1999]

[signature of

litigation guardian]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 11A

rule 11.01(2)(a)

APPLICATION FOR ORDERS IN RESPECT OF JOINDER OF PARTY

[Heading as in Form 5A]

TO [IDENTIFY PERSON PROPOSED TO BE JOINED AND EACH OTHER PARTY]

You are ordered to attend before the Work Health Court for the hearing of an application by [applicant] for orders in respect of the joinder of another * employer/approved insurer */person * as a party to this proceeding.

The applicant alleges:

* under section 55(3) of the Act, that the disease referred to in the worker's claim in this proceeding was contracted while the worker was in the employ of [name of other employer] of [address].

* under section 126A(2)(b)(ii) of the Act, that the approved insurer, [name] of [address], may be liable to indemnify the employer for all or part of the compensation paid to the worker.

[brief description of allegation]

The application will be heard by the Court at [address of Court] at a.m./p.m. on or as soon afterwards as the business of the Court allows.

Dated: [e.g.

1 April 1999]

[signature of applicant

or legal practitioner]

Filed:

Registrar

Do not ignore this notice. If you do not understand this notice or need help contact a Registrar of the Work Health Court, a legal practitioner or your local legal aid office.

Prepared and filed by [footer as in Form 2A]

* Delete if inapplicable.

(NOTES

TO APPLICANT:

1. This application must be supported by an affidavit.

2. A sealed copy of this application is to be served on the party to be joined and each other party. You must file sufficient copies to allow for service of sealed copies.)

FORM 12A

rule 12.02(1)

LIST OF DOCUMENTS

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

I,

[name of party], the [identify party] in this proceeding, say that:

1. I have in my possession, custody or power, the documents enumerated in Part 1 of Schedule 1 relating to the questions in this proceeding.

2. The documents enumerated in Part 2 of Schedule 1 are privileged, and I object to producing them.

The documents are privileged on the following grounds:

(e.g.)

as to documents numbered 4 – 6, that [grounds of privilege];

as to documents numbered 7 – 9, that [grounds of privilege].

3. I have had, but no longer have, in my possession, custody or power, the documents enumerated in Schedule 2 relating to the questions in the proceeding.

(e.g.)

Document numbered [no.] was last in my possession, custody or power on [date] and I believe that [statement of belief as to what has become of it]

4. To the best of my knowledge, information and belief neither I nor my legal practitioner nor any other person on my behalf has now, or ever had, in my or his or her possession, custody or power, any documents relating to a question in the proceeding other than the documents enumerated in Schedules 1 and 2.

Dated: [e.g.

1 April 1999]

[signature of party]

Filed:

Prepared and filed by [footer as in Form 2A]

(NOTE:

A party's legal practitioner may complete this form only if instructed to do so by the party. See rule 1.14.)

SCHEDULE 1

(Describe each document in the Schedules as original or copy and number each of them.)

PART 1

DOCUMENTS IN PARTY'S POSSESSION

PART 2

PRIVILEGED DOCUMENTS

SCHEDULE 2

DOCUMENTS NO LONGER IN PARTY'S POSSESSION

FORM 12B

rule 12.03(1)

REQUIREMENT FOR AFFIDAVIT VERIFYING LIST OF DOCUMENTS

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

You are required by the [requesting party] to make an affidavit verifying your list of documents and to serve the affidavit on the

[requesting party] not later than 14 days after service of this notice on you.

Dated:

[e.g. 1 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared by [footer as in Form 2A]

FORM 12C

Rule 12.05

NOTICE TO PRODUCE DOCUMENTS FOR INSPECTION

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

The

[requesting party] requires you to produce for inspection, not later than 14 days after service of this notice on you, the following documents referred to in your [list of documents, statement of claim, notice of defence, affidavit, &c.]:

[description of documents requested]

You are required to arrange with [requesting party] a time and place for inspection.

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared by [footer as in Form 2A]

FORM 14A

rule 14.03(2)

ADMISSION OF FACTS

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

I,

[party], admit the following facts:

1. [list of facts admitted]

2.

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 14B

rule 14.04(2)

NOTICE TO DISPUTE FACTS

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

If you do not, within [specify a number of days not less than 14] days after service of this notice on you serve a notice on the [party serving this notice] disputing any fact specified below, that fact will, for the purpose of this proceeding only, be taken to be admitted by you in favour of the [party serving this notice].

If you do serve a notice disputing a fact, and afterwards that fact is proved, you must pay the costs of proof unless the Court orders otherwise.

1. [list of facts]

2.

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 14C

rule 14.04(3)

NOTICE DISPUTING FACTS

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

The

[party serving this notice] disputes the following facts specified in the [identify party's] notice dated [e.g. 1

February 1999].

1. [list of disputed facts]

2.

Dated: [e.g.

8 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 14D

rule 14.05(2)

NOTICE TO DISPUTE AUTHENTICITY OF DOCUMENTS

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

If you do not, within [specify a number of days not less than 14] days after service of this notice on you serve a notice on the [party serving this notice] disputing the authenticity of a document specified below, the authenticity of the document will, for the purpose of this proceeding only, be taken to be admitted by you in favour of the [party serving this notice].

If you do serve a notice disputing the authenticity of a document, and afterwards the authenticity of the document is proved, you must pay the costs of proof unless the Court orders otherwise.

1. [list of documents]

2.

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 14E

rule 14.05(3)

NOTICE DISPUTING AUTHENTICITY OF DOCUMENTS

[Heading as in Form 5A]

TO

THE [IDENTIFY PARTY]

The

[party serving this notice] disputes the authenticity of the following documents specified in the [identify party's] notice dated [e.g. 1 February 1999]:

1. [list of disputed documents]

2.

Dated: [e.g.

8 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 15A

rule 15.01(1)

MEMORANDUM OF AGREEMENT

[Heading as in Form 5A]

TO

THE COURT

The

[identify parties] in this proceeding have entered into the following agreement and request the Court to record the agreement.

[details of agreement]

Dated: Dated:

[signed by party] [signed by party]

[PARTY'S

FULL NAME] [PARTY'S

FULL NAME]

Filed:

Prepared and filed by [footer as in Form 2A]

(NOTES

TO PARTIES:

The memorandum of agreement is to be filed accompanied by a document, headed "STATEMENT OF PARTICULARS", including the following particulars as applicable. The statement of particulars is to include details, by the use of

sub-totals, of how the amount of each payment under the agreement is made up or calculated.

1. In the case of an injury suffered or disease contracted by a worker:

worker's full name, address, occupation and date of birth;

employer's full name and address;

date of injury or when disease contracted;

brief statement of injury or disease;

as at the date of injury or contraction of disease:

worker's normal weekly earnings (as defined in section 49 of the

Act);

name of award (if any) under which worker was employed;

amount of sick leave benefit payable under that award;

period(s) of incapacity;

actual earnings of worker during period(s) of incapacity up to the date of this memorandum, giving dates on which variations of earnings occurred;

amount per week worker is reasonably capable of earning in work he/she is capable of undertaking if he/she were to engage in the most profitable employment, if any, reasonably available to him/her, having regard to the matters referred to in section 68 of the Act;

full name of spouse and:

whether wholly or mainly dependent on worker; or

if employed – his or her normal weekly earnings;

full names and dates of birth of prescribed child (as defined in section 65(13) of the Act);

amounts (using sub-totals for each category) previously made for:

weekly payments;

hospital, medical or rehabilitation treatment or training expenses;

amount (using sub-totals for each category) of medical, hospital, rehabilitation or other expenses for which compensation is claimed.

2. In the case of a worker with a permanent impairment:

worker's full name, address, occupation and date of birth;

employer's full name and address;

date of injury or when disease contracted;

brief statement of injury or disease;

percentage of permanent impairment assessed under section 72 of the Act.

In addition to the statement of particulars, copies of the following documents are also to accompany the memorandum of agreement:

all medical reports obtained by the parties in respect of the injury or

all other documents on which the parties relied in reaching agreement, including documents that provide evidence of amounts to be paid under the agreement.

See rule 2.06(3) on how to file accompanying documents.)

FORM 15B

rule 15.02

NOTICE OF RECEIPT OF MEMORANDUM OF AGREEMENT

[Heading as in Form 5A]

TO

[NAME AND ADDRESS OF EACH PARTY AND PERSON HAVING AN INTEREST IN

THE AGREEMENT]

In respect of the claim in this proceeding, the Court has received a request that the Court record a memorandum of agreement between

[identify parties] dated [date]. A copy of the memorandum of agreement is available for inspection at the Registry of the Work Health Court at [address].

If you object to the Court recording the memorandum of agreement you may, NOT LATER THAN 21 DAYS AFTER THE DATE OF THIS NOTICE, file a notice of objection in accordance with Form 15C. A notice of objection is to state the grounds on which the objection is made.

The

Registrar will consider the memorandum of agreement and all objections received and may require the parties to provide further information. The Registrar will then make a report to the Court, after which the Court may:

direct the Registrar to request the parties to the agreement, their legal practitioners or other persons entitled under section 98 of the Act to appear for them, to appear before the Court to provide further information (including copies of documents) and make further submissions as the Court thinks fit;

require the hearing of oral evidence;

summon a person to appear to give evidence; or

direct the Registrar:

not to record the agreement; or

to record the agreement on terms or in its present form.

The

Registrar will notify you accordingly.

Dated:

Registrar

Do not ignore this notice. If you do not understand this notice or need help contact a Registrar of the Work Health Court, a legal practitioner or your local legal aid office.

FORM 15C

rule 15.03(2)

NOTICE OF OBJECTION TO RECORDING MEMORANDUM OF AGREEMENT

[Heading as in Form 5A]

TO

THE COURT

AND

[IDENTIFY EACH PARTY AND PERSON HAVING AN INTEREST IN THE

AGREEMENT]

I,

[name of person objecting], of [address], object to the recording of the memorandum of agreement between [identify parties] dated [date] on the following grounds:

Dated:

[e.g. 1 April 1999]

[signature of person objecting

or legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 15D

rule 15.06(2)(a)

* NOTICE OF DIRECTION NOT TO RECORD AGREEMENT

* NOTICE OF DIRECTION TO RECORD AGREEMENT ON TERMS

[Heading as in Form 5A]

TO

[IDENTIFY EACH PARTY AND PERSON WHO FILED OBJECTION]

On

[date of direction] the Court directed me:

* not to record the memorandum of agreement dated [date of agreement] between [parties].

The reasons for the direction are:

[reasons]

* to record the memorandum of agreement dated [date of agreement] between [parties].

* to record the memorandum of agreement dated [date of agreement] between [parties] on the following terms:

[terms]

I have today recorded the memorandum of agreement in respect of:

* compensation for an injury that occurred on [date]

* compensation for a disease contracted on [date]

* [brief description of other claim]

Dated:

Registrar

* Delete if inapplicable.

FORM 15E

rule 15.07(1)(a)

APPLICATION FOR COMMUTATION OF FUTURE COMPENSATION PAYMENTS

[Heading as in Form 5A]

TO

THE COURT

The

* employer/person to whom compensation is payable * applies for the commutation of future compensation payments under section

* 63/65 * of the Return to Work Act 1986 on the following terms:

(Enter terms.)

STATEMENTS BY EMPLOYER OR PERSON TO WHOM COMPENSATION IS PAYABLE

(Insert required statement(s) in the form of an affidavit or statutory declaration under the Oaths, Affidavits and Declarations

Act 2010.)

Filed:

Prepared and filed by [footer as in Form 2A]

* Delete if inapplicable.

(NOTES

TO APPLICANT:

This application is to be accompanied by a document, headed "STATEMENT

OF PARTICULARS" including details, by the use of sub-totals, of how the amount of commutation is calculated. The following particulars, as applicable, are to be included in the statement of particulars:

1. In the case of section 63 payments:

prescribed child's date of birth;

date of death of worker;

current amount of weekly compensation payments.

2. In the case of section 65 payments:

worker's occupation and date of birth;

date when worker became incapacitated for work;

brief statement of injury out of which incapacity arose;

full name of spouse and:

whether wholly or mainly dependent on worker; or

if employed – his or her normal weekly earnings;

full names and dates of birth of prescribed child (as defined in section 65(13) of the Act);

current amount of weekly compensation payments.

In addition to the statement of particulars, copies of other documents relevant to the proposed commutation are also to accompany this application. See rule 2.06(3) on how to file accompanying documents.

If the other party consents to the commutation, the party may endorse his or her consent on the application.)

FORM 15F

rule 15.07(2)(a)

APPLICATION FOR COMMUTATION OF FUTURE COMPENSATION PAYMENTS

[Heading as in Form 5A]

TO

THE COURT

The worker applies for the commutation of regular compensation payments under section 65 of the Return to Work Act 1986 on the following terms:

(Enter terms.)

STATEMENT BY WORKER

(Insert required statement(s) in the form of an affidavit or statutory declaration under the Oaths, Affidavits and Declarations

Act 2010.)

Filed:

Prepared and filed by [footer as in Form 2A]

(NOTES

TO APPLICANT:

1. This application is to be accompanied by a document headed "STATEMENT

OF PARTICULARS" including details, by the use of sub-totals, of how the amount of commutation is calculated. The following particulars, as applicable, are to be included in the statement of particulars:

worker's occupation and date of birth;

date when worker became incapacitated for work;

brief statement of injury out of which incapacity arose;

full name of spouse and:

whether wholly or mainly dependent on worker; or

if employed – his or her normal weekly earnings;

full names and dates of birth of prescribed child (as defined in section 65(13) of the Act);

current amount of weekly compensation payments.

2. In addition to the statement of particulars, copies of the following documents are also to accompany this application:

statement by person who gave financial counselling and brief details of counselling;

documents on which the parties relied in calculating the commutation.

See rule 2.06(3) on how to file accompanying documents.

If the employer consents to the commutation, the employer may endorse his or her consent on the application.)

FORM 16A

rule 16.03(3)(b)(i)

APPLICATION FOR ORDER PERMITTING EXAMINATION OF WITNESS BY

CLOSED-CIRCUIT TELEVISION COMMUNICATION LINK

[Heading as in Form 5A]

TO

THE COURT

The

[identify party] applies for an order permitting the examination of the witness named below by closed-circuit television communication link at the hearing of this proceeding.

Name of witness:

Date(s) fixed for the hearing:

Time at which it is proposed to examine witness:

* Arrangements for the communication link are as follows:

[details of arrangements]

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

* Delete if inapplicable.

Prepared and filed by [footer as in Form 2A]

FORM 16B

rule 16.03(4)

NOTICE OF OBJECTION TO EXAMINATION OF WITNESS BY CLOSED-CIRCUIT

TELEVISION COMMUNICATION LINK

[Heading as in Form 5A]

TO

THE COURT

AND

TO [IDENTIFY PARTY]

The

[identify party], objects to the Court making an order permitting the examination of a witness, [name], by closed-circuit television communication link at the hearing of this proceeding.

The objection is based on the following ground(s):

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 16C

rule 16.03(9)(b)

NOTICE OF CLOSED-CIRCUIT TELEVISION COMMUNICATION LINK RESERVATION

[Heading as in Form 5A]

TO

THE COURT

I/We,

[name of person or firm], request you to reserve the Court's closed-circuit television communication link as detailed below and pre-arranged in accordance with rule 16.03(9)(a).

Name of witness:

Date and time:

Other facility:

Telephone number of other facility:

(Repeat above details for each witness, as necessary.)

* I/We require the use of a document camera.

* I/We do not require the use of a document camera.

UNDERTAKING

* I/We *,

[name], undertake:

to pay to the Court the costs of the communication link referred to above, including transmission costs, at the rates advised by the officer of the Court with whom arrangements for the reservation were made; and

to indemnify the Court against liability for any charges that may be made by other providers of facilities in relation to this communication link.

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 17A

rule 17.01(1)

AFFIDAVIT

[Heading as in Form 5A]

NAME

OF DEPONENT:

DATE

AFFIDAVIT MADE:

I,

[full name of deponent], [occupation or description], of [deponent's residential address or, if making affidavit in professional or occupational capacity, business address and position and, if applicable, name of firm or employer], make oath and say that:

1. (Divide into paragraphs, numbered consecutively. Confine each paragraph as far as possible to a distinct portion of the subject.)

By

[signature of deponent]

Witnessed by

Signature______________________________________________________

Justice of the peace / commissioner for oaths

Name________________________________________________________

Address or phone no. __________________________________________

Prepared and filed by [footer as in Form 2A]

*

Delete if inapplicable.

FORM 19A

rule 19.03(1)(a)

SUMMONS TO GIVE EVIDENCE

[Heading as in Form 5A]

TO

[NAME]

OF

[ADDRESS]

THE

COURT ORDERS that you attend for the purpose of giving evidence:

before the Work Health Court;

at

[address of Court];

at

[time] on [date] and until you are excused from further attending.

Issued:

Registrar

NOTES

TO PERSON SERVED WITH SUMMONS:

1. If you do not comply with this summons you may be arrested.

2. Any question concerning this summons should be addressed initially to [name of legal practitioner or party], not to the Court.

3. Conduct money must be given or offered with this summons.

Do not ignore this summons. If, after contacting the person named in

note 2, you still do not understand this summons or need help, contact a Registrar of the Work Health Court, a legal practitioner or your local legal aid office.

Prepared and filed by [footer as in Form 2A]

FORM 19B

rule 19.04(a)

SUMMONS FOR PRODUCTION OF DOCUMENTS

[Heading as in Form 5A]

TO

[NAME]

OF

[ADDRESS]

THE

COURT ORDERS that you attend, and bring with you this summons and the documents and things described in the Schedule, at the Work Health

Court at [address] at [time] on [date] and until you are excused from further attending.

Instead of attending, you may take this summons and the documents and things described in the Schedule to a Registrar of the Work Health Court at

[address] by hand or by post, in either case so that the Registrar receives them no later than 2 business days before the date on which you are required to attend.

SCHEDULE

[description of documents and things]

Issued:

Registrar

NOTES

TO PERSON SERVED WITH SUMMONS:

1. If you do not comply with this summons you may be arrested.

2. Documents and things taken to the Court by you may be returned by post to you at your address shown on this summons. You may request in writing that they be posted to you at another address or you may ask to collect them from the Court.

3. Any question concerning this summons should be addressed initially to [name of legal practitioner or party], not to the Court.

4. Conduct money must be given or offered with this summons.

Do not ignore this summons. If, after contacting the person named in

note 3, you still do not understand this summons or need help, contact a Registrar of the Work Health Court, a legal practitioner or your local legal aid office.

Prepared and filed by [footer as in Form 2A]

FORM 19C

rule 19.04(b)

SUMMONS TO CORPORATION FOR PRODUCTION OF DOCUMENTS

[Heading as in Form 5A]

TO

[NAME OF CORPORATION]

OF

[ADDRESS]

THE

COURT ORDERS that:

1. [Name of corporation], called the corporation, must produce this summons and the documents and things described in the Schedule by an appropriate officer attending and producing them at the Work Health Court at [address] at [time] on

[date] and until you are excused from further attending.

Instead of attending, the corporation may produce this summons and the documents and things described in the Schedule to a Registrar of the Work Health Court at [address] by hand or by post, in either case so that the Registrar receives them not later than 2 business days before the date on which the officer is required to attend.

2. The officer who is to attend must make enquiries for the purpose of answering, and on attending must answer, the questions that the

Court requires the officer to answer concerning the possession or custody of those documents and things.

SCHEDULE

[description of documents and things]

Issued:

Registrar

NOTES

TO PERSON SERVED WITH SUMMONS:

1. If you do not comply with this summons an officer of the corporation may be arrested.

2. Documents and things taken to Court by the corporation may be returned by post to the corporation at its address shown on this summons. It may request in writing that they be posted to it at another address or it may ask to collect them from the Court.

3. Any question concerning this summons should be addressed initially to [name of legal practitioner or party], not to the Court.

4. Conduct money must be given or offered with this summons.

Do not ignore this summons. If, after contacting the person named in

note 3, you still do not understand this summons or need help, contact a Registrar of the Work Health Court, a legal practitioner or your local legal aid office.

Prepared and filed by [footer as in Form 2A]

FORM 20A

rule 20.01

NOTICE OF HEARING

[Heading as in Form 5A]

The hearing of this proceeding has been listed to take place at the Work

Health Court at [address] at a.m./p.m.

on or as soon afterwards as the business of the Court allows.

Dated:

Registrar

FORM 22A

rule 22.01(a)

DRAFT FINAL ORDER

[Heading as in Form 5A]

JUDICIAL

OFFICER: [Name]

DATE

MADE:

HOW

OBTAINED:

APPEARANCE: (Set out appearance or non-appearance of any person entitled to attend and, if attending, whether by legal practitioner.)

OTHER

MATTERS: (State any finding of jurisdictional fact, undertaking of party or other matter as directed by Court.)

THE

COURT ORDERS THAT:

1. [terms of order]

2.

Dated:

BY THE COURT

Registrar/Magistrate

Do not ignore this order. If you do not understand this order or need help contact a Registrar of the Local Court, a legal practitioner or your local legal aid office.

Prepared and filed by [footer as in Form 2A]

FORM 22B

rule 22.02(1)

NOTICE REQUESTING AMENDMENT OF DRAFT FINAL ORDER

[Heading as in Form 5A]

TO

[IDENTIFY PARTY]

The

[identify party] requests an amendment of the terms of the final order, made in this proceeding on [date], as contained in the draft final order served on [date]. The amendment requested is as follows:

(Specify amendment requested.)

Dated:

[Signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]

FORM 22C

rule 22.02(2)(b)

NOTICE OF REFUSAL TO AMEND DRAFT FINAL ORDER

[Heading as in Form 5A]

TO

THE COURT AND [IDENTIFY PARTY]

The

[identify party] refuses to amend the terms of the final order as requested in the notice dated [date] and applies for a determination of the Court in respect of the terms of the final order made in this proceeding on [date].

The application will be heard by the Court at [address of Court] at a.m./p.m. on or as soon afterwards as the business of the Court allows.

Dated: [e.g.

1 April 1999]

[signature of party or

legal practitioner]

Filed:

Registrar

Prepared and filed by [footer as in Form 2A]

FORM 23A

rule 23.09(1)(a)

SUMMONS FOR TAXATION OF COSTS

[Heading as in Form 5A]

TO [IDENTIFY

ADDRESS OF EACH PERSON NOT A PARTY]

You are summoned to attend before the taxing officer at [address of

Court] at a.m./p.m. on

for the hearing of an application by [identify party] for the costs that are payable to that party by [identify party liable for costs] under [identify the judgment, etc., by which payable] to be taxed in accordance with the bill of costs served with this summons.

Issued:

Registrar

NOTE

TO PERSON SERVED WITH SUMMONS:

Whether or not you attend on the day for hearing referred to above, the costs claimed in the bill may be allowed unless, not later than 7 days before the date fixed for taxation, you file and serve on the

[identify party filing summons] a notice in accordance with

Form 23B identifying by list each item in the bill to which you object and stating specifically and concisely the grounds of objection to each item. Failure to file that notice amounts to an admission of the items in the bill.

Prepared and filed by [footer as in Form 2A]

FORM 23B

rule 23.10(1)

NOTICE OF OBJECTION TO BILL OF COSTS

[Heading as in Form 5A]

TO [identify party]

The [objecting party] objects to the items in your bill of costs specified below for the reasons specified in relation to each item.

(List items objected to and state specifically and concisely the grounds of objection to each item.)

Dated:

[Signature of party or

legal practitioner]

Filed:

Prepared and filed by [footer as in Form 2A]