SCHEDULE.
(Form 1. Reg. 3.)
APPLICATION FOR ARBITRATION BY AN INJURED WORKER
AS TO COMPENSATION PAYABLE TO HIM.

In the [Northern] Industrial District.

In the matter of "The Workers' Compensation for Accidents
Act, 1900"; and in the matter of an arbitration between
A. B., of [Address and description],
Claimant,
And
C. D. and Co., of [Address and description],
Respondents.

An arbitration under "The Workers' Compensation for Acci-
dents Act, 1900," is hereby applied for between the above-
named parties as to the amount of compensation payable to
the claimant under the Act in respect of personal injury
caused to him by accident arising out of and in course of
his employment.

Particulars.

1. Name and address of injured worker ..
2. Name, place of business, and nature of busi-
   ness of respondents .. .. ..
3. Nature of employment of worker at time of
   accident, and whether employed under
   respondents or under contractors with
   them [If employed under contractors who
   are not respondents, name and place of
   business of contractors to be stated]
   ..
4. Date and place of accident .. .. ..
5. Nature of work on which worker was then
   engaged, and nature of accident, and
   cause of injury .. .. ..
6. Nature of injury .. .. ..
7. Particulars of incapacity for work, whether
   partial or total, and estimated duration
   of incapacity .. .. ..
8. Average weekly earnings during twelve
   months previous to injury, if the worker
   was so long employed under the re-
   sondents, or, if not, during the time he
   was so employed .. .. ..
9. Estimated average amount which the worker
   is able to earn after the accident ..
10. Payments (not being wages) received from
    respondents in respect of the injury during
    the period of incapacity .. ..
11. Amount of fines (if any) under any Act ap-
    plied for benefit of injured worker ..
12. Amount claimed as compensation ..
13. Date of service of statutory notice of acci-
    dent on respondents, and whether given
    before worker voluntarily left the re-
    spondents' employment [A copy of the
    notice to be annexed] .. .. ..
14. If notice not served, why not .. ..

Dated the day of , 19 .
(Signed)
A. B., Claimant
[or Claimant's solicitor].
The name and address of the claimant's solicitor
is

3. Nature of employment of deceased worker
   at time of accident, and whether em-
   ployed under respondents or under con-
   tractors with them [If employed under
   contractors who are not respondents, name
   and place of business of contractors to be
   stated] .. .. .. .. ..
4. Date and place of accident .. ..
5. Nature of work on which deceased worker
   was then engaged, and nature of accident
   and cause of injury .. .. ..
6. Nature of injury to deceased and date of
   death .. .. .. .. ..
7. Earnings of deceased worker during three
   years next preceding injury, if he was so
   long in the employment of the same em-
   ployer; and, if not, particulars of his
   average weekly earnings during the
   period of such employment .. ..
8. Amount of weekly payments (if any) made
   to deceased worker under the Act ..
9. Amount of fines (if any) under any Act
   applied for benefit of deceased worker or
   his dependants .. .. .. .. ..
10. Character in which applicant applies—i.e.,
    whether as legal personal representative
    of deceased worker or as a dependant; if
    the latter, particulars showing how he
    is so .. .. .. .. ..
11. Particulars as to dependants of deceased
    worker by whom or on whose behalf the
    application is made, giving their names,
    addresses, and occupations, and, if minors,
    their respective ages, and stating whether
    they were wholly or partially dependent
    on the earnings of the deceased worker
    at the time of his death .. ..
12. Particulars as to any persons claiming to
    be dependants, but as to whose claim a
    question arises, and who are therefore
    made respondents; with their names,
    addresses, and occupations .. ..
13. Amount claimed as compensation, and
    showing how claimant proposes such
    amount should be apportioned and
    applied .. .. .. .. ..
14. Date of service of statutory notice of acci-
    dent on respondents from whom compen-
    sation is claimed, and whether given
    before deceased worker voluntarily left
    the employment in which he was injured
    [A copy of the notice to be annexed] ..
15. If notice not served, why not .. ..

Dated, &c. [as in Form 1].

(Form 3. Reg. 3.)
APPLICATION for ARBITRATION as to who are DEPENDANTS,
or as to the Amount payable to each Dependant; the
total Amount of Compensation payable having been
agreed or ascertained.

[Heading as in Form 1.]

AN arbitration under "The Workers' Compensation for
Accidents Act, 1900," is hereby applied for between E. F.,
the legal personal representative of A. B., deceased (acting on
behalf of G. B., H. B., &c., dependants of the said A. B.), and
C. D. and Co.; and L. M., N.O., &c., who claim to be de-
pendants of the said A. B. [or as the case may be], to settle
questions as to who are dependants of the said A. B., and as
to the apportionment and application of the agreed [or
ascertained] amount of compensation under the Act in
respect of the injury which resulted in the death of the said
A. B., caused by accident arising out of and in course of his
employment.

Particulars.

1. [As 1 in Form 2.]
2. Name and place of business of employers by
   whom compensation has been paid or is
   payable .. .. .. .. ..
3. Date of accident to deceased worker, and
   date of death .. .. .. ..
4. Agreed or ascertained amount of compensa-
   tion to be paid to dependants of deceased
   worker .. .. .. ..
5. Particulars as to whether the compensation
   money is still payable or has been paid,
   and, if so, to whom, and in whose hands
   it now is .. .. .. ..
6. [As 9 in Form 2.]

(Form 2. Reg. 3.)
APPLICATION for ARBITRATION by LEGAL PERSONAL RE-
PRESENTATIVE OF DECEASED WORKER on behalf of his
Dependants, or by Dependants where no Legal Personal
Representative, as to Compensation payable, and the
Settlement of Questions as to who are Dependants,
and the Apportionment and Application of such Com-
pensation.

[Heading as in Form 1. See Reg. 25.]

AN arbitration, under "The Workers' Compensation for Ac-
cidents Act, 1900," is hereby applied for between E. F., the
legal personal representative of A.B., deceased, acting on
behalf of the dependants of the said A. B. [or between
G. B., a dependant of A. B., deceased] and C. D. and Co.,
and L. M., who claim to be dependants of the said A. B.
[or as the case may be], as to the compensation payable
to the dependants of the said A. B. under the Act in
respect of the injury which resulted in the death of the said
A. B., caused by accident arising out of and in course of his
employment, and the settlement of questions as to who
are dependants, and the apportionment and application of
such compensation.

Particulars.

1. Name and late address of deceased worker
2. Name, place of business, and nature of
   business of respondents from whom com-
   pensation is claimed .. .. ..