WORKERS REHABILITATION AND COMPENSATION ACT 1988 ELECTION TO COMMENCE

NETWORKERS AND THEIR ACTIVITY IN INTENSIONAL NETWORKS
WORKERS’ COMPENSATION DIVISION WORKER’S AND HEALTH CARE
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WORKERS REHABILITATION

WORKERS REHABILITATION AND COMPENSATION ACT 1988

ELECTION TO COMMENCE PROCEEDINGS FOR DAMAGES

(Section 138AB)

Degree of permanent impairment agreed by Employer

I ____________________________________________________________________

of ___________________________________________________________________

being a worker who alleges to have suffered an injury in circumstances described in Part X of the Act, hereby elect to claim damages in respect of that injury.

The relevant details are:

Date of Injury _________________________________________________________

Name of Employer _____________________________________________________

Address of Employer ___________________________________________________

Name of Insurer _______________________________________________________

Address of Insurer _____________________________________________________

I have been assessed as suffering a permanent impairment of ___________ percent of the whole person in accordance with assessment conducted pursuant to Section 72 and 73 of the Act.

Dated this _______________ day of _________________________ 200

Signed:___________________________

Name:____________________________

(worker)

Name:____________________________

(employer)

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