Image unavailable in extracted textREGULATIONS UNDER THE COMMONWEALTH EMPLOYEES’
COMPENSATION ACT 1930-1959.*
I, ADMINISTRATOR of the Government of the Commonwealth of Australia, acting with the advice of the Federal Executive Council, hereby make the following Regulations under the Commonwealth Employees’ Compensation Act 1930-1959.
Dated this 10th
day of February, 1961.
DALLAS BROOKS
ADMINISTRATOR
By His Excellency’s Command,
Harold Holt
Treasurer.
Image unavailable in extracted textCOMMONWEALTH EMPLOYEES’ COMPENSATION
REGULATIONS.
Citation.
These Regulations may be cited as the Commonwealth Employees’ Compensation Regulations.
Repeal.
The Employees’ Compensation Regulations (comprising Statutory Rules 1953, Nos. 22 and 73; Statutory Rules 1954, No. 19; Statutory Rules 1958, No. 40 and Statutory Rules 1960, No. 42) are repealed.
Definitions
In these Regulations, unless the contrary intention appears—
“authority” means an authority of the Commonwealth specified in regulation 14 of these Regulations;
“the Act” means the Commonwealth Employees’ Compensation Act 1930-1959.
Claim for compensation
4.—(1.) A claim for compensation under the Act shall be addressed to the Permanent Head or Chief Officer of the Department or authority in or by which the employee was employed at the time when the injury, incapacity, or death upon which the claim is based occurred and shall be—
Image unavailable in extracted text(a) sent by post in an envelope so addressed on which the postage has been prepaid;
* Notified in the Commonwealth Gazette on 16th February, 1961.
2560/60.—Price 8d. 10/9.12.1960
(b) delivered to the head office of that Department or authority; or
(c) delivered to the officer in charge of the work on which the employee was so employed.
(2.) In the application of this regulation in relation to a claim in respect of an employee who is suffering from a disease, or whose death has been caused by a disease, that was due to the nature of his employment in more than one Department or authority, the claim shall be sent or delivered in accordance with paragraph (a) or (b) of the last preceding sub-regulation as if the disease was contracted where he was last so employed.
(3.) A claim for compensation under the Act by an employee shall be in accordance with Form A in the Schedule to these Regulations.
(4.) A claim for compensation under the Act by a dependant shall be in accordance with Form B in the Schedule to these Regulations.
Election under section 15 of the Act.
5. An election made by an employee under section 15 of the Act shall be in accordance with Form C in the Schedule to these Regulations.
Appointment of medical boards.
The Commissioner may, from time to time, appoint such medical boards as are required.
Medical examinations
The medical practitioner, medical referee, or medical board to whom or to which a matter is referred under section 19 of the Act shall, if so required by the Commissioner, give a certificate in accordance with Form D in the Schedule to these Regulations 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 more frequently 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.
10.—(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 service of the notice of the determination or action appealed against, 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 twenty-one 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.
Coats of appeal.
11.—(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 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 were 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 in the Schedule to these Regulations 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 extends are as follows:—
Australian Aluminium Production Commission;
Australian Atomic Energy Commission;
Australian Broadcasting Commission;
Australian Services Canteens Organization;
Australian Stevedoring Industry Authority;
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 Banking Corporation;
Commonwealth Scientific and Industrial Research Organization;
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 Trustees of the Canberra Public Cemetery;
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.
16.—(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 Commissioner may—
(a) in the case of death of the employee—pay the amount to a Savings Bank account in the name of the Commissioner specifying the persons so entitled; and
(b) in any other case—pay the amount 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 the Commissioner pays the amount to a Savings Bank account in pursuance of the last preceding sub-regulation, the Commissioner may authorize, upon such conditions as he determines, a person to withdraw moneys from that account, and those moneys shall be dealt with for the benefit of the persons entitled to those moneys in such manner as the Commissioner directs.
(3.) Where a determination is varied by the Commissioner in pursuance of paragraph (9.) of the First Schedule to the Act, a trust created under the Act or this regulation ceases and determines as from the date of the variation, and trust moneys then held shall be dealt with in such manner as the Commissioner directs.
(4.) The determination of a trust by the operation of the last preceding sub-regulation does not prejudice a right of action against a trustee in respect of an act or omission occurring before 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 commissioned officer of the Defence Force who has attained the age of twenty-one years;
(c) a police, stipendiary or special magistrate of the Commonwealth or of a State;
(d) a justice of the peace;
(e) a barrister or solicitor, a notary public, a commissioner for affidavits, or a commissioner for declarations;
(f) a legally qualified medical practitioner;
(g) a minister of religion;
(h) a member of the police force of the Commonwealth or of a State;
(i) a permanent officer of the Public Service of the Commonwealth who has attained the age of twenty-one years;
(j) a postmaster or postmistress, or person in charge of a post office; or
(k) a head-teacher of a State school.
Compliance with forms.
Strict compliance with the forms in the Schedule to these Regulations is not necessary and substantial compliance is sufficient.
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THE SCHEDULE.
Form A.
Regulation 4(3.).
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 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.
1. State the date of your birth .. .. .. ..
2. 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? .. .. .. ..
3. 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 full particulars of journey.. ..
4. 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 did you first become aware that you were suffering from the disease? .. .. .. ..
(e) When were you first incapacitated by the disease? ..
(f) For what period were you engaged in your employ-ment? .. .. .. .. ..
(g) If you have previously suffered from the disease, state—
(i) Approximate date on which the disease first manifested itself .. .. ..
(ii) Extent to which the disease interfered with your employment .. .. ..
5. 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="width:490.3pt; border-collapse:collapse"><tbody><tr style="height:30.6pt"><td colspan="5" style="width:363.5pt; 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 style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Questions and Requests for Information.</span></p></td><td style="width:118.8pt; 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 style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Replies.</span></p></td></tr><tr style="height:21.35pt"><td colspan="5" style="width:363.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-top:2pt; margin-left:38.3pt; text-indent:-26.95pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>6. Have you engaged in any employment since date of your injury or commencement of incapacity?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:118.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:9.75pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:38.35pt; text-indent:-13.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If so, give full particulars</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:13.1pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:38.55pt; margin-bottom:3pt; text-indent:-13.6pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>State wages received</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span></span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:42.7pt"><td colspan="5" style="width:363.5pt; 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 style="margin-top:2pt; margin-left:38.3pt; margin-bottom:3pt; text-indent:-26.95pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>7. If this claim is made more than six months after occurrence of accident or after your first becoming aware that you were suffering from the disease, give reasons for failure to make claim within that period..</span><span> </span><span>..</span><span></span></p></td><td style="width:118.8pt; 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:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:28.8pt"><td colspan="5" style="width:363.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-top:2pt; margin-left:38.3pt; text-indent:-26.95pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>8. Are you receiving or entitled to receive from the Commonwealth any payment, allowance or benefit in respect of your incapacity under—</span></p></td><td style="width:118.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:9pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(</span><span style="font-style:italic">a</span><span>)</span><span style="font-style:italic"> Repatriation Act </span><span>1920-19</span><span style="width:0.15pt; text-indent:0pt; display:inline-block"> </span><span>, e.g., pension;</span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:25.45pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(</span><span style="font-style:italic">b</span><span>)</span><span style="font-style:italic"> Social Services Act </span><span>1947-19</span><span style="width:24.86pt; text-indent:0pt; display:inline-block"> </span><span>, e.g., unemployment, sickness, or rehabilitation benefits or invalid pension;</span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:19.55pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(</span><span style="font-style:italic">c</span><span>) any other law (other than </span><span style="font-style:italic">Commonwealth Employees’ Compensation Act </span><span>1930-19</span><span style="width:5.63pt; text-indent:0pt; display:inline-block"> </span><span>)?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:12.6pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:24.95pt; margin-bottom:3pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If so, give full particulars</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:48.1pt"><td colspan="5" rowspan="2" style="width:363.5pt; 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 style="margin-top:2pt; margin-left:38.3pt; text-indent:-26.95pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>9. 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) in respect of the incapacity? ..</span><span> </span><span>..</span><span> </span><span>..</span><span></span></p><p style="margin-left:24.95pt; margin-bottom:3pt; text-align:justify; font-size:11pt"><span>If so, do you intend taking proceedings in respect of that other claim?</span><span> </span><span>..</span></p></td><td style="width:118.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:21.6pt"><td style="width:118.8pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:22.1pt"><td colspan="5" rowspan="4" style="width:363.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-top:2pt; margin-left:38.3pt; text-indent:-26.95pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>10. [To</span><span style="font-style:italic"> be answered only if you have one of the following persons dependent upon your earnings.</span><span>]</span></p><p style="margin-left:29.35pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>Give particulars (including full name) of one of following:—</span></p><p style="margin-left:78.85pt; text-indent:-27pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(</span><span style="font-style:italic">a</span><span>)</span><span style="font-style:italic"> </span><span>your wife; or</span></p><p style="margin-left:78.85pt; text-indent:-27pt; text-align:justify; font-size:11pt"><span>(</span><span style="font-style:italic">b</span><span>)</span><span style="font-style:italic"> </span><span>Female over age of 16 years caring for a child wholly or mainly dependent upon your earnings and under age of 16 years; or</span></p></td><td style="width:118.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.25pt"><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:5.9pt"><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:30.1pt"><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:7.45pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:51.85pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(</span><span style="font-style:italic">c</span><span>) female member of your family over 16 years of age</span><span style="width:68.61pt; font-family:'Lucida Console', monospace; display:inline-block">..........</span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:7.45pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:29.35pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>Was she wholly dependent upon your earnings at date of injury?</span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:7.45pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:29.35pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If not, state extent of dependence</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:9.75pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:29.35pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>Has she continuously remained so dependent?</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:7.45pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:29.35pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>Is she now so dependent?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:22.65pt"><td colspan="5" style="width:363.5pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:43.1pt; margin-bottom:3pt; text-indent:-13.6pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If there has been any change in her dependence upon your earnings since the date of injury, give full particulars</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span></span></p></td><td style="width:118.8pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:31.1pt"><td colspan="5" style="width:363.5pt; 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 style="margin-top:2pt; margin-left:38.3pt; margin-bottom:8pt; text-indent:-26.95pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>11. [</span><span style="font-style:italic">To be answered only if you have at least one child under </span><span>16 </span><span style="font-style:italic">years of age dependent upon your earnings.</span><span>]</span></p></td><td style="width:118.8pt; 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:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:37.3pt"><td style="width:136.4pt; 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 style="margin-top:6pt; margin-bottom:3pt; text-align:center; widows:2; orphans:2; font-size:10pt"><span>Full name of each child under 16 years of age dependent upon your earnings.</span></p></td><td style="width:52.4pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Age.</span></p></td><td style="width:52.05pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Date of birth.</span></p></td><td style="width:83.75pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Relationship to you.</span></p></td><td colspan="2" style="width:145.7pt; 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 style="margin-top:6pt; margin-bottom:3pt; text-align:center; widows:2; orphans:2; font-size:10pt"><span>State whether wholly, mainly or partially (giving full particulars) dependent upon your earnings.</span></p></td></tr><tr style="height:50.4pt"><td style="width:136.4pt; 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 style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td><td style="width:52.4pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td><td style="width:52.05pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td><td style="width:83.75pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td><td colspan="2" style="width:145.7pt; 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:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:140.4pt"></td><td style="width:56.4pt"></td><td style="width:56.05pt"></td><td style="width:87.75pt"></td><td style="width:26.9pt"></td><td style="width:122.8pt"></td></tr></tbody></table>
Declared at on the day of , 19 .
Signature of Declarant.
Before me—
The Schedule—continued.
Form B.
Regulation 4(4.).
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:—
<table cellspacing="0" cellpadding="0" style="width:490.3pt; border-collapse:collapse"><tbody><tr style="height:32.4pt"><td style="width:369.5pt; 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 style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Questions and Requests for Information.</span></p></td><td style="width:112.8pt; 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 style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Replies.</span></p></td></tr><tr style="height:21.35pt"><td style="width:369.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:38.35pt; text-indent:-27pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>1. On date of injury, above-named employee was employed—</span></p></td><td style="width:112.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:9pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(a) In what precise capacity?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.5pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(b) By what Department or Authority?</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.75pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:29.35pt; text-indent:-4.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If he was a member of the Defence Force at date of injury—</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.25pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(c) What was his rank?</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:14.15pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; margin-bottom:3pt; text-indent:-31.45pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(d) What was his unit?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:11.85pt"><td style="width:369.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-top:2pt; margin-left:38.3pt; text-indent:-26.95pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>2. If death of employee was caused by injury by accident—</span></p></td><td style="width:112.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.25pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(a) What was nature of injury?</span><span> </span><span></span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.25pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(b) At what hour did injury occur? </span><span></span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.5pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(c) On what date did injury occur?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:9.25pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(d) Where did injury occur?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.5pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(e) Describe briefly how injury was caused</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:17.25pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(f) Give names of any persons who were present at time of</span></p><p style="margin-left:83.35pt; text-indent:-0.55pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>accident or immediately afterwards .</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:48.35pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:83.35pt; margin-bottom:3pt; text-indent:-31.45pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(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 full particulars of journey </span><span></span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:12.35pt"><td rowspan="9" style="width:369.5pt; 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 style="margin-top:2pt; margin-left:38.3pt; text-indent:-26.95pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>3. If death of employee was caused by a disease—</span></p><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(a) What was nature of disease?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(b) How was disease caused?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(c) When was disease caused?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(d) When was employee first incapacitated by the disease?</span></p><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(e) For what period was employee engaged in his employment?</span><span> </span><span>..</span></p><p style="margin-left:83.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(f) If employee ever previously suffered from the disease, state—</span></p><p style="margin-left:110.35pt; text-indent:-31.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(i) Approximate date on which the disease first manifested itself</span></p><p style="margin-left:110.25pt; margin-bottom:3pt; text-indent:-34pt; text-align:justify; font-size:11pt"><span>(ii) Extent to which the disease interfered with his employment</span></p></td><td style="width:112.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.25pt"><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.25pt"><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.75pt"><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:9.25pt"><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:16.2pt"><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:17.25pt"><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:16.95pt"><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:23.15pt"><td style="width:112.8pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:12.35pt"><td style="width:369.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:38.35pt; text-indent:-27pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>4. Was notice of accident or incapacity served?</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.25pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:29.35pt; text-indent:-4.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>On whom was notice served?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:13.9pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:29.35pt; text-indent:-4.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>On what date was notice served?</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:16.95pt"><td style="width:369.5pt; 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 style="margin-top:3pt; margin-left:38.3pt; margin-bottom:3pt; text-indent:-26.95pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>5. What is your relationship to deceased employee?</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; 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:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:17.7pt"><td style="width:369.5pt; 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 style="margin-top:3pt; margin-left:38.3pt; margin-bottom:3pt; text-indent:-26.95pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>6. Were you wholly dependent upon employee’s earnings at date of his death?</span></p></td><td style="width:112.8pt; 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:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:8.7pt"><td style="width:369.5pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:38.35pt; text-indent:-27pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>7. Were you in part dependent upon employee’s earnings at date of his death?</span></p></td><td style="width:112.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:3.5pt"><td style="width:369.5pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:bottom"><p style="margin-left:29.35pt; text-indent:-4.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If so, give full particulars</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:112.8pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr></tbody></table>
The Schedule—continued.
<table cellspacing="0" cellpadding="0" style="width:490.3pt; border-collapse:collapse"><tbody><tr style="height:30.1pt"><td colspan="6" style="width:362.1pt; 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 style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Questions and Requests for Information.</span></p></td><td style="width:120.2pt; 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 style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Replies.</span></p></td></tr><tr style="height:18.6pt"><td style="width:23pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:8pt; margin-right:7.1pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span>8</span></p></td><td colspan="5" style="width:335.1pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:8pt; margin-left:11.6pt; text-indent:-11.6pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>Was any other person contributing towards your maintenance at date of employee’s death? </span><span></span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:120.2pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:12.1pt"><td style="width:23pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span></span></p></td><td colspan="5" style="width:335.1pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:11.6pt; margin-bottom:3pt; text-indent:-11.6pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If so, give full particulars</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:120.2pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:29.3pt"><td style="width:23pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span>9</span></p></td><td colspan="5" style="width:335.1pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-left:11.5pt; text-indent:-11.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>Were you in receipt of a pension or other payment (other than Child Endowment) from the Commonwealth at the date of employee’s death?</span></p></td><td style="width:120.2pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:13.9pt"><td style="width:23pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span></span></p></td><td colspan="5" style="width:335.1pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:11.6pt; margin-bottom:3pt; text-indent:-11.6pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If so, give full particulars</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:120.2pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:12.75pt"><td style="width:23pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span>10</span></p></td><td colspan="5" style="width:335.1pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-left:11.5pt; text-indent:-11.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>Did you at date of employee’s death have any other means of</span></p><p style="margin-left:11.6pt; text-indent:1.7pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>support?</span><span> </span><span></span><span>..</span><span> </span><span></span><span>..</span><span> </span><span></span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:120.2pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:14.9pt"><td style="width:23pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span></span></p></td><td colspan="5" style="width:335.1pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:11.6pt; margin-bottom:3pt; text-indent:-11.6pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If so, give full particulars</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:120.2pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:30.85pt"><td style="width:23pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span>11.</span></p></td><td colspan="5" style="width:335.1pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-left:11.5pt; text-indent:-11.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>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:120.2pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:9pt"><td style="width:23pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span></span></p></td><td colspan="5" style="width:335.1pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:47.5pt; text-indent:-27pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(</span><span style="font-style:italic">a</span><span>)</span><span style="font-style:italic"> Repatriation Act </span><span>1920-19</span><span style="width:7pt; text-indent:0pt; display:inline-block"> </span><span>, e.g., pension;</span></p></td><td style="width:120.2pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:17.25pt"><td style="width:23pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span></span></p></td><td colspan="5" style="width:335.1pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:47.5pt; text-indent:-27pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(</span><span style="font-style:italic">b</span><span>) </span><span style="font-style:italic">Social Services Act </span><span>1947-19</span><span style="width:4.71pt; text-indent:0pt; display:inline-block"> </span><span>, e.g., unemployment, sickness or rehabilitation benefits or invalid pension;</span><span></span></p></td><td style="width:120.2pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:15.7pt"><td style="width:23pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span></span></p></td><td colspan="5" style="width:335.1pt; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:47.5pt; text-indent:-27pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>(</span><span style="font-style:italic">c</span><span>)</span><span style="font-style:italic"> </span><span>any other law (other than </span><span style="font-style:italic">Commonwealth Employees’ Compensation Act </span><span>1930-19</span><span style="width:0.98pt; text-indent:0pt; display:inline-block"> </span><span>)?</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:120.2pt; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:14.4pt"><td style="width:23pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span></span></p></td><td colspan="5" style="width:335.1pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:11.6pt; margin-bottom:3pt; text-indent:-11.6pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If so, give full particulars</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:120.2pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:47.05pt"><td style="width:23pt; border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span>12.</span></p></td><td colspan="5" style="width:335.1pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-left:11.5pt; text-indent:-11.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>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> </span><span>..</span></p></td><td style="width:120.2pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:15.3pt"><td style="width:23pt; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span></span></p></td><td colspan="5" style="width:335.1pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:11.6pt; margin-bottom:3pt; text-indent:-11.6pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If so, do you intend taking proceedings in respect of that other claim?</span></p></td><td style="width:120.2pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:34.95pt"><td style="width:23pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-right:7.2pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span>13.</span></p></td><td colspan="5" style="width:335.1pt; 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 style="margin-top:3pt; margin-left:11.6pt; margin-bottom:3pt; text-indent:-11.6pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>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> </span><span>..</span></p></td><td style="width:120.2pt; 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:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:34.45pt"><td style="width:23pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-right:7.2pt; margin-bottom:3pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span>14.</span></p></td><td colspan="5" style="width:335.1pt; 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 style="margin-top:3pt; margin-left:11.5pt; margin-bottom:3pt; text-indent:-11.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>If this claim is made more than six months after advice of the employee’s death was received by you, give reasons for failure to make claim within that period</span><span> </span><span>..</span><span> </span><span>..</span><span> </span><span>..</span></p></td><td style="width:120.2pt; 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:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:30.85pt"><td style="width:23pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-right:7.2pt; margin-bottom:8pt; text-align:right; widows:2; orphans:2; font-size:11pt"><span>15.</span></p></td><td colspan="5" style="width:335.1pt; 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 style="margin-top:3pt; margin-left:11.5pt; margin-bottom:8pt; text-indent:-11.5pt; text-align:justify; widows:2; orphans:2; font-size:11pt"><span>[</span><span style="font-style:italic">To be answered only if there was at least one child under sixteen years of age dependent upon deceased employee’s earnings.</span><span>]</span></p></td><td style="width:120.2pt; 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:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:50.65pt"><td colspan="2" style="width:134.25pt; 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 style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Full name of each child dependent upon deceased employee’s earnings.</span></p></td><td style="width:52.3pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Age.</span></p></td><td style="width:51.25pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Date of Birth.</span></p></td><td style="width:82.65pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>Relationship to deceased employee.</span></p></td><td colspan="2" style="width:149.85pt; 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 style="text-align:center; widows:2; orphans:2; font-size:10pt"><span>State whether wholly, mainly or partially (giving full particulars) dependent upon employee’s earnings at date of his death.</span></p></td></tr><tr style="height:71.25pt"><td colspan="2" style="width:134.25pt; 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 style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td><td style="width:52.3pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td><td style="width:51.25pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td><td style="width:82.65pt; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td><td colspan="2" style="width:149.85pt; 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:bottom"><p style="text-align:justify; widows:2; orphans:2; font-size:10pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:27pt"></td><td style="width:111.25pt"></td><td style="width:56.3pt"></td><td style="width:55.25pt"></td><td style="width:86.65pt"></td><td style="width:29.65pt"></td><td style="width:124.2pt"></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.
Image unavailable in extracted textImage unavailable in extracted textForm D.