1
Employees' Compensation Regulations
STATUTORY RULES.
1953. No. 22.
REGULATIONS UNDER THE COMMONWEALTH EMPLOYEES’ COMPENSATION ACT 1930-1951.*
I, THE GOVERNOR-GENERAL in and over the Commonwealth of Australia, acting with the advice of the Federal Executive Council, hereby make the following Regulations under the Commonwealth Employees’ Compensation Act 1930-1951.
Dated this fourteenth day of March, 1953.
(Sgd) W. J. McKell
Governor-General.
By His Excellency’s Command,
Treasurer.
Employees’ Compensation Regulations.
Citation.
- These Regulations may be cited as the Employees’ Compensation Regulations.
Repeal.
- The Employees’ Compensation Regulations (comprising Statutory Rules 1945, No. 23; Statutory Rules 1946, No. 37; Statutory Rules 1947, Nos. 27 and 132; Statutory Rules 1948, No. 13; Statutory Rules 1949, No. 90; and Statutory Rules 1951, No. 2) are repealed.
Definitions.
3.—(1.) In these Regulations, unless the contrary intention appears—
“authority” means an authority of the Commonwealth specified in regulation 15 of these Regulations;
“the Act” means the Commonwealth Employees’ Compensation Act 1930-1951.
(2.) A reference in these Regulations to a Form by letter shall be read as a reference to the Form so lettered in the Schedule to these Regulations.
Claim by employee or dependant.
4.—(1.) A claim for compensation under the Act shall be delivered or sent by post by an employee, or in the case of a dependant claiming compensation in respect of the death of an employee, by the dependant, to the Permanent Head or Chief Officer of the Department or authority in or by which the employee was employed, or to the officer in charge of the work on which the employee was employed, at the time when the injury, incapacity or death upon which the claim is based occurred.
(2.) A claim for compensation under the Act by an employee shall be in accordance with Form A.
(3.) A claim for compensation under the Act by a dependant shall be in accordance with Form B.
Election under section 15 of the Act.
- An election made by an employee under section 15 of the Act shall be in accordance with Form C.
_________________________________________________________________________________
* Notified in the Commonwealth Gazette on , 1953.
4160.—Price 8d. 10/5.2.1953.
Fees to medical referee.
- The fees to be paid to a medical referee are Three pounds three shillings for a first examination and One pound eleven shillings and sixpence for a subsequent examination.
Appointment of medical boards.
- The Commissioner may, from time to time, appoint such medical boards as are required.
Medical examinations.
- The medical referee, medical practitioner, or medical board to whom or to which a matter is referred, shall give a certificate in accordance with Form D and shall forward it to the Commissioner or his delegate as soon as possible after the examination.
Time for nomination by employee of representative on medical board.
- An employee who is required by the Commissioner in pursuance of section 19 of the Act to submit himself for examination by a medical board, may, within seven days of the date on which he is so required, nominate a medical practitioner to be one of the members of the board.
Frequency of medical examinations.
- An employee who has made a claim for compensation, or is in receipt of weekly payments, under the Act shall not be required after a period of one month has elapsed from the date on which the first payment of compensation was made, to submit himself against his will for examination by a medical referee, a medical board, or a medical practitioner, provided and paid by the Commonwealth, except at reasonable hours and not at more frequent intervals than once a week during the second month, once a month during the third, fourth, fifth, and sixth months after the date on which the first payment of compensation was made and, thereafter, once in every two months.
Appeals.
11.—(1.) An appeal under section 20 of the Act may be instituted by notice of appeal in accordance with this regulation.
(2.) The person appealing shall, within thirty days after the determination or action appealed against is made or taken, serve the notice of appeal on the Commissioner and shall file a copy of the notice of appeal in the County Court.
(3.) The notice of appeal shall state the grounds of appeal.
(4.) A person who intends to apply to the Court for extension of the time for appeal shall serve on the Commissioner not less than seven days’ notice of his intention to apply for extension of the time for appeal.
(5.) Where, upon an application for extension of the time for appeal, the Court extends the time for appeal, the person appealing shall serve on the Commissioner the notice of appeal together with a copy of the Order of the Court extending the time for appeal.
(6.) Unless the Court otherwise orders, the date fixed for the hearing of the appeal shall be not less than thirty days after the service on the Commissioner of the notice of appeal.
Costs of appeal.
12.—(1.) The allowance of the costs of and incidental to an appeal under section 20 of the Act (including an adjournment), or to an application for an extension of the time for appeal, to be paid by one party to another, shall be in the discretion of the County Court to which the application or appeal is made, and the Court shall have full power to allow or disallow the costs.
(2.) A Court which allows costs in pursuance of the last preceding sub-regulation shall make an order directing by whom and to whom the costs are to be paid, and costs so awarded shall, in default of
agreement between the parties as to the amount of the costs, be taxed according to the scale which would be applicable if the proceeding had been an action in the Court, and the laws in force for the time being with respect to the allowance and taxation of costs in an action in the Court and with respect to objections and the review of taxation by the taxing officer shall apply accordingly.
(3.) Where the subject-matter of the application or appeal is not a capital sum, the Court shall, for the purpose of the allowance and the taxation of costs, direct what shall be considered to be the amount of the subject-matter of the application or appeal and, in default of a direction, the amount shall be fixed by the taxing officer by whom the costs are to be taxed, subject to review by the Court.
(4.) Where there is no provision for the taxing of costs in the Court, the Court shall, in default of agreement between the parties as to the amount of the costs, fix the amount of the costs.
(5.) An order for the payment of costs made by the Court in pursuance of this regulation shall have the same force and effect in all respects as a judgment of the Court and the like proceedings (including proceedings in bankruptcy) may be taken upon the order as if it was a judgment of the Court for the amount of the costs.
(6.) In this regulation “taxing officer” means the Registrar, Clerk of the Court or other person having power to tax the costs of an action in the Court.
Returns by Departments.
- The Permanent Head or Chief Officer of each Department and authority shall furnish to the Commissioner not later than the thirty-first day of July, in each year, a correct return in accordance with Form E of payments made under the Act during the twelve months ended on the preceding thirtieth day of June.
Returns by Commissioner to Treasurer.
- As soon as possible after the close of each financial year, the Commissioner shall furnish to the Treasurer a correct return specifying—
(a) the number of cases in respect of which compensation has been paid under the Act during that year;
(b) the amount of compensation paid during that year; and
(c) the amount paid in respect of medical and funeral expenses during that year.
Commonwealth authorities.
- The authorities of the Commonwealth to the employees of which the application of the Act shall extend are as follows:—
Army Canteens Service Board;
Australian Aluminium Production Commission;
Australian Broadcasting Commission;
Australian Shipping Board;
Australian Stevedoring Industry Board;
Board of Management appointed under the Australian War Memorial Act 1925-1952;
Bush Fire Council appointed under the Careless Use of Fire Ordinance 1936 of the Australian Capital Territory, or that Ordinance as amended;
Canberra Community Hospital Board;
Commonwealth Bank of Australia;
Commonwealth Scientific and Industrial Research Organization;
Commonwealth Railways Commissioner;
Commonwealth Savings Bank of Australia;
Director of Shipping;
Overseas Telecommunications Commission (Australia);
R.A.A.F. Canteens Service Board;
State Rifle Associations, District Rifle Club Unions, Miniature Rifle Club Unions, rifle clubs and miniature rifle clubs formed or established in accordance with, or under, the Australian Rifle Club Regulations;
The Council of the Canberra University College;
Trustees of the Services Canteens Trust Fund.
Special liability of Commonwealth.
- Liability under the Act to pay compensation in respect of personal injury by accident arising out of or in the course of the employment on a rifle range of an employee of a State Rifle Association, District Rifle Club Union, Miniature Rifle Club Union, rifle club or miniature rifle club who is employed in the actual conduct of a rifle practice or competition, shall be borne by the Commonwealth.
Payment of compensation to trustees.
17.—(1.) Where the Act provides that an amount of compensation shall be paid to the Commissioner and invested or applied or dealt with by him in such manner as he thinks fit for the benefit of the persons entitled to that amount, the amount may be paid to such trustee or trustees as the Commissioner appoints to be held for the benefit of the persons so entitled upon such trusts as are approved by the Commissioner.
(2.) Where a determination is varied by the Commissioner in pursuance of paragraph (9.) of the First Schedule to the Act, a trust created under this regulation shall cease and determine as from the date of the variation, and trust moneys then held shall be dealt with in such manner as the Commissioner directs.
(3.) The determination of a trust by operation of the last preceding sub-regulation shall not prejudice a right of action against a trustee in respect of an act or omission occurring prior to the date of the variation.
Declarations.
- A declaration under these Regulations may be made before—
(a) a member of the Parliament of the Commonwealth or of a State, or a councillor or alderman of a municipality or shire;
(b) a police, stipendiary or special magistrate of the Commonwealth or of a State;
(c) a justice of the peace;
(d) a barrister or solicitor, a notary public, a commissioner for affidavits, or a commissioner for declarations;
(e) a legally qualified medical practitioner;
(f) a minister of religion;
(g) a member of the police force of the Commonwealth or of a State;
(h) an adult permanent officer of the Public Service of the Commonwealth;
(i) a postmaster or postmistress, or person in charge of a post office; or
(j) a head-teacher of a State school.
Compliance with forms.
- Strict compliance with the forms in the Schedule shall not be required and substantial compliance therewith shall suffice for the purposes of these Regulations.
THE SCHEDULE.
Form a.
Regulation 4 (2.).
Commonwealth Employees’ Compensation Act 1930-19
Claim for Compensation.
CLAIM BY INCAPACITATED EMPLOYEE.
To—
I, [here write full name] of [here write full postal address] hereby claim compensation under the above-mentioned Act in respect of personal injury sustained by me and arising out of or in the course of my employment by the Commonwealth and declare that, to the best of my knowledge and belief, the following replies to the questions and requests for information are true and correct in every particular:—
| Questions and Requests for Information. | Replies. |
|---|---|
| State the date of your birth....................................... | |
| On date of injury you were employed:— | |
| (a) In what precise capacity?................................... | |
| (b) By what Department or Authority?............................. | |
| If you were a member of the Defence Force at date of injury— | |
| (c) What was your rank?...................................... | |
| (d) What was your unit?...................................... | |
| If you are claiming in respect of incapacity arising from injury by accident:— | |
| (a) What is the nature of your injury?............................. | |
| (b) At what hour did injury occur?............................... | |
| (c) On what date did injury occur?............................... | |
| (d) Where did injury occur?.................................... | |
| (e) Describe briefly how injury was caused.......................... | |
| (f) Were you incapacitated for work?.............................. | |
| (g) On what date were you incapacitated for work?..................... | |
| (h) Give names of any persons who were present at time of accident or immediately afterwards | |
| (i) If accident occurred whilst travelling to or from your employment, training school or any place to obtain a medical certificate or to receive medical treatment or compensation in respect of a previous injury, give particulars of journey | |
| If you are claiming in respect of incapacity arising from a disease:— | |
| (a) What is nature of disease?................................... | |
| (b) How was disease caused?................................... | |
| (c) When was disease caused?.................................. | |
| (d) When were you first incapacitated by such disease?.................. | |
| (e) For what period were you engaged in your employment?.............. | |
| (f) If you have previously suffered from such disease, state:— | |
| (i) Approximate date on which such disease first manifested itself....... | |
| (ii) Extent to which such disease interfered with your employment...... | |
| Was notice of accident or incapacity served?........................... | |
| On whom was notice served?..................................... | |
| On what date was notice served?................................... |
The Schedule—continued.
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr style="height:29.5pt"><td colspan="5" style="width:378.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Questions and Requests for Information.</span></p></td><td style="width:99.95pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Replies.</span></p></td></tr><tr style="height:27.6pt"><td colspan="5" style="width:378.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Have you engaged in any employment since date of your injury or commencement of incapacity?</span><span style="width:3.15pt; text-indent:0pt; display:inline-block"></span></p></td><td style="width:99.95pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:8.15pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="text-indent:20.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If so, give full particulars</span><span style="width:247.46pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.....................................</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:12.25pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">State wages received</span><span style="width:287.22pt; font-family:'Lucida Console', monospace; display:inline-block">...........................................</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:32.15pt"><td colspan="5" style="width:378.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If this claim is made more than six months after occurrence of accident or commencement of incapacity, give reasons </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">for </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">failure to make claim within that period</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt"></span></p></td><td style="width:99.95pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:27.35pt"><td colspan="5" style="width:378.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Are </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">you </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">receiving or </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">entitled </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">to receive from </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">the </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Commonwealth any payment, allowance </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">or </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">benefit </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">in respect of your incapacity </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">under—</span></p></td><td style="width:99.95pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:7.7pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:55.6pt; text-indent:-32.05pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">(</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">a</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">) </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Repatriation</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Act</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">1920-19</span><span style="width:28.45pt; text-indent:0pt; display:inline-block"> </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">, </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">e</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">.g., pension;</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:24.5pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:55.6pt; text-indent:-31.95pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle267" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal; letter-spacing:normal">(</span><span class="FontStyle267" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; letter-spacing:normal">b</span><span class="FontStyle267" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal; letter-spacing:normal">) </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Social</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Services</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Consolidation</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Act</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">1947-19</span><span style="width:23.97pt; text-indent:0pt; display:inline-block"> </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">, </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">e.g., un</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">employment, sickness, or rehabilitation benefits </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">or </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">invalid pension;</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:16.1pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style110" style="margin-left:55.6pt; text-indent:-32.05pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">(</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt; font-style:italic">c</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">) any other law (other than </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Commonwealth</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Employees’</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Compensation</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Act</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">1930-19</span><span style="width:33.93pt; text-indent:0pt; display:inline-block"> </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">)?</span><span style="width:27.45pt; text-indent:0pt; display:inline-block"></span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:12pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="text-indent:11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If so, give particulars</span><span style="width:274.48pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.........................................</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:43.9pt"><td colspan="5" style="width:378.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Have you another claim or right to claim against the Commonwealth or another person for compensation or damages or for any payment (other than a payment under an insurance policy privately effected by you or from a friendly society) </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">in </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">respect of the incapacity?</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt"></span></p></td><td style="width:99.95pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:20.15pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="text-indent:11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If so, do you intend taking proceedings </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">in </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">respect of that other claim</span><span style="width:67.06pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">..........</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:14.15pt"><td colspan="5" style="width:378.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Give particulars including full name of one of following:</span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">—</span></p></td><td style="width:99.95pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:8.15pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:56.5pt; text-indent:-31.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">(</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">a</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">) </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">your wife; </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">or</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:24pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:56.5pt; text-indent:-31.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">(</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt; font-style:italic">b</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">) female over age of 16 years caring </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">for </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">a child wholly or mainly dependent upon your earnings and under age of 16 years; or</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:13.8pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:38.5pt; text-indent:-13.5pt; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">(</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt; font-style:italic">c</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">) female member of your family over 16 years of age</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:13.9pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Was she wholly or mainly dependent upon your earnings at date of injury?</span><span style="width:50.76pt; font-family:'Lucida Console', monospace; display:inline-block">.......</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:7.9pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Has she continuously remained so dependent?</span><span style="width:176.31pt; font-family:'Lucida Console', monospace; display:inline-block">..........................</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:8.15pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Is she now so dependent?</span><span style="width:267.03pt; font-family:'Lucida Console', monospace; display:inline-block">........................................</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:7.7pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If not, state extent of dependence</span><span style="width:233.46pt; font-family:'Lucida Console', monospace; display:inline-block">...................................</span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:34.3pt"><td colspan="5" style="width:378.5pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If she was not </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">wholly </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">or mainly dependent upon your earnings at date </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">of </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">injury </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">but has </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">since </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">become </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">so </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">dependent, </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">give particulars</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt"></span></p></td><td style="width:99.95pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:14.1pt"><td colspan="6" style="width:482.45pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:34.55pt"><td style="width:135.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Full name of each child under 16 years of age dependent upon your earnings.</span></p></td><td style="width:63.5pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Age.</span></p></td><td style="width:50pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Date of birth.</span></p></td><td style="width:90.5pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Relationship to you.</span></p></td><td colspan="2" style="width:126.95pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">State whether wholly, mainly or partially (giving full particulars) dependent upon your earnings.</span></p></td></tr><tr style="height:53.5pt"><td style="width:135.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:63.5pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:50pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:90.5pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="width:126.95pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:0pt"><td style="width:139.5pt"></td><td style="width:67.5pt"></td><td style="width:54pt"></td><td style="width:94.5pt"></td><td style="width:27pt"></td><td style="width:103.95pt"></td></tr></tbody></table>
Declared at on the day of , 19 .
Signature of Declarant.
Before me—
The Schedule—continued.
Form B.
Regulation 4 (3.).
Commonwealth Employees’ Compensation Act 1930-19 .
Claim for Compensation.
CLAIM BY DEPENDANT OF EMPLOYEE.
To—
I, [here write full name] of [here write full postal address] hereby claim compensation under the above-mentioned Act for myself and children named below in respect of the death of [here write full name of deceased employee] and declare that, to the best of my knowledge and belief, the following replies to the questions and requests for information are true and correct in every particular:—
| Questions and Requests for Information. | Replies. |
|---|---|
| On date of injury, above-named employee was employed:— | |
| (a) In what precise capacity?..................................... | |
| (b) By what Department or Authority?.............................. | |
| If he was a member of the Defence Forces at date of injury— | |
| (c) What was his rank?......................................... | |
| (d) What was his unit?......................................... | |
| If death of employee was caused by injury by accident:— | |
| (a) What was nature of injury?................................... | |
| (b) At what hour did injury occur?................................. | |
| (c) On what date did injury occur?................................. | |
| (d) Where did injury occur?..................................... | |
| (e) Describe briefly how injury was caused........................... | |
| (f) Give names of any persons who were present at time of accident or immediately afterwards | |
| (g) If accident occurred whilst employee was travelling to or from his employment, training school or any place to obtain a medical certificate or to receive medical treatment or compensation in respect of a previous injury, give particulars of journey | |
| If death of employee was caused by a disease:— | |
| (a) What was nature of disease?................................... | |
| (b) How was disease caused?.................................... | |
| (c) When was disease caused?.................................... | |
| (d) When was employee first incapacitated by such disease?................ | |
| (e) For what period was employee engaged in his employment?.............. | |
| (f) If employee ever previously suffered from such disease, state:— | |
| (i) Approximate date on which such disease first manifested itself...... | |
| (ii) Extent to which such disease interfered with his employment....... | |
| Was notice of accident or incapacity served?............................. | |
| On whom was notice served?....................................... | |
| On what date was notice served?..................................... | |
| What is your relationship to deceased employee?.......................... | |
| Were you wholly dependent upon employee’s earnings at date of his death?........ | |
| Were you in part dependent upon employee’s earnings at date of his death?......... | |
| If so, give full particulars.......................................... |
The Schedule—continued.
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr style="height:30.7pt"><td colspan="5" style="width:392pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Questions </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:10pt">and </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Requests for Information.</span></p></td><td style="width:87.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p class="Style227" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:10pt">Replies.</span></p></td></tr><tr style="height:29.3pt"><td colspan="5" style="width:392pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Was any other person contributing towards your maintenance at date of employee’s death?</span><span style="width:32.48pt; text-indent:0pt; display:inline-block"></span></p></td><td style="width:87.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:12.7pt"><td colspan="5" style="width:392pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="text-indent:22.3pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If so, give full particulars</span><span style="width:257.91pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">......................................</span></p></td><td style="width:87.35pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:26.15pt"><td colspan="5" style="width:392pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Were you in receipt of a pension </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">or </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">other payment (other than Child Endowment) from the Commonwealth at the date of employee’s death?</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt"></span></p></td><td style="width:87.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:12pt"><td colspan="5" style="width:392pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="text-indent:22.75pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If so, give particulars</span><span style="width:275.48pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.........................................</span></p></td><td style="width:87.35pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:18.7pt"><td colspan="5" style="width:392pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Did you at date of employee’s death have any other means of support?</span><span style="width:81.36pt; font-family:'Lucida Console', monospace; display:inline-block">............</span></p></td><td style="width:87.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:15.1pt"><td colspan="5" style="width:392pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="text-indent:22.75pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If so, give full particulars</span><span style="width:257.46pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">......................................</span></p></td><td style="width:87.35pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:26.15pt"><td colspan="5" style="width:392pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Are you receiving or entitled to receive from the Commonwealth in respect of the death of the employee, or was the employee receiving or entitled to receive, any payment under—</span></p></td><td style="width:87.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:9.85pt"><td colspan="5" style="width:392pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="text-indent:22.7pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">(</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">a</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">) </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Repatriation</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Act</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">1920-19</span><span style="width:33.6pt; text-indent:0pt; display:inline-block"> </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">, e.g., pension;</span><span style="width:143.24pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.....................</span></p></td><td style="width:87.35pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:14.15pt"><td colspan="5" style="width:392pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style110" style="margin-left:56.45pt; text-indent:-33.75pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">(</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt; font-style:italic">b</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">) any other law (other than </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt; font-style:italic">C</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">ommonwealth</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Employees’</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Compensation</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Act</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">1930-19</span><span style="width:34.16pt; text-indent:0pt; display:inline-block"> </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">)</span><span style="width:32.34pt; text-indent:0pt; display:inline-block"></span></p></td><td style="width:87.35pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:12pt"><td colspan="5" style="width:392pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="text-indent:11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If so, give particulars?</span><span style="width:281.85pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">..........................................</span></p></td><td style="width:87.35pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:44.15pt"><td colspan="5" style="width:392pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Have you another claim or right to claim against the Commonwealth or another person for compensation or damages or for any payment (other than a payment under an insurance policy privately effected by employee or from a friendly society) in respect of death of employee</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt"></span></p></td><td style="width:87.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:20.4pt"><td colspan="5" style="width:392pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="text-indent:22.3pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If so, do you intend taking proceedings in respect of that other claim?</span><span style="width:63.63pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.........</span></p></td><td style="width:87.35pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:31.45pt"><td colspan="5" style="width:392pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Give names, addresses and relationships to deceased employee of all other persons (except children) known to you, who were dependent upon his earnings at date of his death</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt"></span></p></td><td style="width:87.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:36pt"><td colspan="5" style="width:392pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p class="Style227" style="margin-left:11.5pt; text-indent:-11.5pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">If this claim is made more than six months after employee’s death, give reasons for failure to make claim within that period</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt"></span></p></td><td style="width:87.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:14.55pt"><td colspan="6" style="width:483.35pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:46.8pt"><td style="width:126.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Full name of each child dependent upon deceased employee’s earnings.</span></p></td><td style="width:54.5pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Age.</span></p></td><td style="width:68pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Date of Birth.</span></p></td><td style="width:77pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">Relationship to deceased employee.</span></p></td><td colspan="2" style="width:141.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p class="Style123" style="text-align:center; widows:2; orphans:2; font-size:10pt"><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">State whether wholly, mainly or partially (giving full particulars) dependent upon employee</span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:10pt">’s </span><span class="FontStyle335" style="font-family:'Times New Roman', serif; font-size:10pt; font-weight:normal">earnings at date of his death.</span></p></td></tr><tr style="height:89.05pt"><td style="width:126.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:54.5pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:68pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:77pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="width:141.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:0pt"><td style="width:130.5pt"></td><td style="width:58.5pt"></td><td style="width:72pt"></td><td style="width:81pt"></td><td style="width:54pt"></td><td style="width:91.35pt"></td></tr></tbody></table>
Declared at on the day of , 19 .
Signature of Declarant.
Before me—
The Schedule—continued.
Form C.
Regulation 5.
Commonwealth Employees’ Compensation Act 1930-19
ELECTION UNDER SECTION 15.
I, of , being a person entitled to elect to take compensation or benefits under the Commonwealth Employees’ Compensation Act 1930-19 , or under the provisions of a determination made by the Public Service Arbitrator appointed under the Public Service Arbitration Act 1920-19 , in respect of personal injury by accident arising out of or in the course of my employment by the Commonwealth, hereby elect to take compensation or benefits under the Commonwealth Employees’ Compensation Act 1930-19 .
[Signature of Employee.]
Signed before me this day of , 19 .
Signature of witness.
Occupation and address of witness.
Form D.
Regulation 8.
Commonwealth Employees’ Compensation Act 1930-19 .
REPORT OF MEDICAL REFEREE, MEDICAL BOARD OR MEDICAL PRACTITIONER.
*I, *a Medical Referee
We, a Medical Board
a Medical Practitioner
acting under the Commonwealth Employees’ Compensation Act 1930-19 , have this day examined of , whose signature appears in the margin of this Form, a claimant for compensation under the above-named Act. On examination—
*I,/We, find that claimant is about years of age and is suffering from (a)
The above condition is the result of (b)
and is such that the claimant is thereby incapacitated at present to the extent of per cent. of total incapacity at his employment at the date of the injury, and per cent. of total incapacity in the general labour market.
Claimant is fit to undertake employment in such occupations as
(c) The above condition is the result of (d)
disease which *was/was not due to the nature of his employment by the Commonwealth
In *my/our opinion claimant *has /has not previously suffered from the above-mentioned disease
General Remarks—
*Medical Referee.
Medical Board.
Medical Practitioner.
Date , 19 .
_________________________________________________________________________________
* Strike out what is inapplicable.
(a) Fully describe claimant’s general condition.
(b) State whether injury by accident or disease.
(c) This part to be filled in only in case of claimant suffering from a disease.
(d) State nature of disease.
The Schedule—continued.
Form E.
Regulation 13.
Commonwealth Employees’ Compensation Act 1930-19 .
RETURN OF PAYMENTS MADE DURING THE YEAR ENDED
30th JUNE, 19 .
<table cellspacing="0" cellpadding="0" style="width:487.35pt; border-collapse:collapse"><tbody><tr style="height:9.1pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style108" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">D</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">epartment </span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">or</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal"> </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Au</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">thority</span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:8.9pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style106" style="widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:middle"><p class="Style74" style="text-align:center; widows:2; orphans:2; font-size:11pt"><span class="FontStyle277" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">£</span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:middle"><p class="Style110" style="text-align:center; widows:2; orphans:2; font-size:11pt"><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">s</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">.</span></p></td><td style="width:19.85pt; padding-right:2pt; padding-left:2pt; vertical-align:middle"><p class="Style110" style="text-align:center; widows:2; orphans:2; font-size:11pt"><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">d</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">.</span></p></td></tr><tr style="height:6.7pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">1. </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Amount paid under Section </span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">9 </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">(General Accidents)—</span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:7.7pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="text-indent:34pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">(</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">a</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">) </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">in cases of incapacity</span><span style="width:279.55pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">..........................................</span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:14.15pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="text-indent:34pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">(</span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:italic">b</span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">) </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">in cases of death</span><span style="width:300.93pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.............................................</span></p></td><td style="width:14pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:15.85pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style106" style="widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:10.3pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">2. </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Amount paid under Section </span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">9</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">a </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">(Travelling)—</span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:7.7pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="text-indent:34pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">(</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">a</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">) </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">in cases </span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">of </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">incapacity</span><span style="width:279.4pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">..........................................</span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:13.9pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="text-indent:34pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">(</span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:italic">b</span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">) </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">in cases </span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">of </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">death</span><span style="width:300.78pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.............................................</span></p></td><td style="width:14pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:16.1pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style106" style="widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:11.3pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">3. </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Amount paid under Section </span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">10 </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">(Diseases)—</span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:8.15pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="text-indent:34pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">(</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">a</span><span class="FontStyle238" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:normal">) </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">in cases of incapacity</span><span style="width:279.4pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">..........................................</span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:12.5pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="text-indent:34pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">(</span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal; font-style:italic">b</span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">) </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">in cases of death</span><span style="width:300.78pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.............................................</span></p></td><td style="width:14pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:19.05pt"><td style="width:423.5pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:13pt"><td style="width:423.5pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">4. </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Amount paid under Section </span><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">12 </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">(Specified Injuries)</span><span style="width:189.35pt; font-family:'Lucida Console', monospace; display:inline-block">............................</span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:14.4pt"><td style="width:423.5pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style108" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">T</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">otal </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">A</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">mount of </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">C</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">ompensation </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">P</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">aid </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">D</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">uring the year</span><span style="width:189.03pt; font-family:'Lucida Console', monospace; font-variant:small-caps; display:inline-block">............................</span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:17.3pt"><td style="width:423.5pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle312" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">5. </span><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Amount paid in respect of medical and funeral expenses</span><span style="width:164.94pt; font-family:'Lucida Console', monospace; display:inline-block">........................</span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:16.3pt"><td style="width:423.5pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style108" style="widows:2; orphans:2; font-size:11pt"><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">T</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">otal </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">A</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">mount </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">P</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">aid </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">U</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">nder the </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">A</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">ct </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">D</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">uring the </span><span class="FontStyle314" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">Y</span><span class="FontStyle232" style="font-family:'Times New Roman', serif; font-size:11pt; font-weight:normal">ear</span><span style="width:199.74pt; font-family:'Lucida Console', monospace; font-variant:small-caps; display:inline-block">..............................</span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:33.9pt"><td style="width:423.5pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style109" style="margin-left:34pt; text-indent:-34pt; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Number of injuries in respect of which payments have been made under the Act during the year</span><span style="width:2.44pt; text-indent:0pt; display:inline-block"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.85pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p class="Style106" style="text-align:justify; widows:2; orphans:2; font-size:11pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:21.85pt"><td colspan="4" style="width:483.35pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style106" style="text-indent:304pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Permanent Head or Chief</span></p></td></tr><tr style="height:5.55pt"><td colspan="4" style="width:483.35pt; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style106" style="text-indent:281.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span class="FontStyle264" style="font-family:'Times New Roman', serif; font-size:11pt">Officer of the Department or Authority.</span></p></td></tr><tr style="height:21.85pt"><td colspan="4" style="width:483.35pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:bottom"><p class="Style106" style="margin-bottom:3pt; text-indent:11.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span class="FontStyle338" style="font-family:'Times New Roman', serif; font-size:11pt">Date</span></p></td></tr></tbody></table>
By Authority: L. F. Johnston, Commonwealth Government Printer, Canberra.