1064
THE NEW ZEALAND GAZETTE.
[No. 48

7. Particulars as to persons claiming to be dependants 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 or claim to have been wholly or partially dependent on the earnings of the deceased worker at the time of his death

8. The like particulars as to any dependants who are made respondents

9. [As 11 in Form 2.]

10. Particulars of the manner in which the claimant proposes the amount of compensation should be apportioned and applied

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

(Form 4. Reg. 3.)

APPLICATION FOR ARBITRATION BY LEGAL PERSONAL REPRESENTATIVE OF DECEASED WORKER as to Compensation payable in respect of Expenses of Medical Attendance and Burial, or by Person to whom such Expenses are due, where Deceased leaves no Dependants.

[Heading as in Form 1.]

AN arbitration under “The Workers’ Compensation for Accidents Act, 1900,” is hereby applied for between E. F. and C. D. and Co. and G. H. as to the compensation payable under the Act in respect of the reasonable expenses of medical attendance on and the burial of A. B., deceased, whose death resulted from injury caused to the said A. B. by accident arising out of and in course of his employment, and the apportionment and application of such amount.

Particulars.

1 to 6. [As 1 to 6 in Form 2.]

7. Character in which claimant applies—i.e., whether as legal personal representative of deceased worker, or as a person to whom expenses in respect of which compensation is payable are due; if the latter, particulars of the circumstances under which the expenses are claimed to be due to the claimant

8. Particulars as to any other persons who claim that expenses in respect of which compensation is payable are due to them, and who are therefore made respondents, with their names and addresses

9. [As 12 in Form 2.]

10 and 11. [As 13 and 14 in Form 2.]

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

(Form 5. Reg. 8.)

NOTICE TO CLAIMANT OF DAY ON WHICH ARBITRATION WILL BE PROCEEDED WITH.

[Heading as in Form 1.]

TAKE notice that the Court will proceed with the arbitration in this matter at , on , the day of , at the hour of in the noon.

To

, Clerk of Awards.

(Form 6. Reg. 8.)

NOTICE TO RESPONDENTS.

[Heading as in Form 1.]

TAKE notice that the Court will proceed with the arbitration applied for in the application (a sealed copy of which is served herewith) at , on , the day of , at the hour of in the noon; and that if you do not attend either in person or by your solicitor at the time and place above mentioned such order will be made and proceedings taken as the Court thinks just and expedient.

And further take notice that if you—
(1.) Wish to disclaim any interest in the subject-matter of the arbitration; or
(2.) Consider that the claimant’s particulars are in any respect incorrect or incomplete; or
(3.) Desire to bring any fact or document before the Court; or
(4.) Intend to rely on any fact; or
(5.) Intend to deny (wholly or partially) your liability to pay compensation under the Act,—
you must file with me an answer, stating your name and address and the name and address of your solicitor (if any), and stating that you disclaim any interest in the subject-matter of the arbitration, or in what respect the claimant’s particulars are incorrect or incomplete, or stating concisely any fact or document you desire to bring before the Court, or on which you rely, or the grounds on and the extent to which you deny liability to pay compensation.

Such answer, together with three copies thereof for the Court and one copy for the claimant and for each of the other respondents, must be filed with me five clear days at least before the day of .

If no answer is filed, and subject to such answer if any, the claimant’s particulars and your liability to pay compensation will be taken to be admitted.

Dated this day of , 19 .

To

, Clerk of Awards.

(Form 7. Reg. 11.)

ANSWER BY RESPONDENTS.

[Heading as in Form 1.]

TAKE notice that the respondents, C. D. and Co., state that claimant’s particulars filed in this matter are inaccurate or incomplete in the following particulars:—

Or

That the respondents, C. D. and Co., desire to bring to the notice of the Court the following facts:—

That the claimant, A. B., refuses to submit himself to medical examination as required by the respondents, C. D. and Co., in accordance with clause 5 of the Second Schedule to the Act [or obstructs the medical examination required by the respondents, C. D. and Co., in accordance with clause 5 of the Second Schedule to the Act, or as the case may be].

Or

That the respondents, C. D. and Co., intend at the hearing of the arbitration to give in evidence and rely on the following facts:—

That no notice of the alleged accident was given to the respondents as required by section 12 of the Act. Or

That the claim for compensation with respect to the alleged accident was not made within three months from the occurrence of the accident [or within six months of the death of the said A. B.] Or

That a scheme of compensation for the workers of the respondents, C. D. and Co., in employment as , has been duly certified by the Board of Conciliation, and such certificate has not been revoked; and the said C. D. and Co. contracted with the said A. B. by a contract which was in force at the date of the alleged accident that the provisions of the said scheme should be substituted for the provisions of the Act; and the said C. D. and Co. are consequently liable only in accordance with the said scheme.

Or

That the respondents, C. D. and Co., deny their liability to pay compensation under the said Act in respect of the injury to A. B. mentioned in the claimant’s particulars, on the grounds—

That the employment of the said A. B. was not an employment to which the Act applies. Or

That the injury to the said A. B. was not caused by accident arising out of and in course of his employment. Or

That the injury to the said A. B. is attributable to the serious and wilful misconduct of the said A. B. Or

That at the time of the alleged accident the said A. B. was not immediately employed by the respondents, C. D. and Co., but was employed by , of , a contractor with the said C. D. and Co., in the execution by the said of work which was merely incidental to and was no part of or process in the trade or business carried on by the said C. D. and Co. [or as the case may be].

Or

That the respondent, G. H., disclaims any interest in the subject-matter of the above arbitration.

And take notice that the names and addresses of the said respondents and their solicitors are,—

Of the respondents:

Of their solicitors:

Dated this day of , 19 .

(Signed)

Solicitors for the Respondents,

C. D. and Co.

To the Clerk of Awards, and to the claimant, A. B., and to the respondents [if any, naming them].

(Form 8. Reg. 14.)

NOTICE BY RESPONDENT ADMITTING LIABILITY, AND SUBMITTING TO AWARD FOR PAYMENT OF A WEEKLY SUM OR PAYING MONEY INTO COURT.

[Heading as in Form 1.]

TAKE notice that the respondents, C. D. and Co., admit their liability to pay compensation in the above-mentioned matter. And they hereby submit to an award for payment by them to the claimant, A. B., of the weekly sum of , such