NSW WORKERS COMPENSATION

Transcription

1 NSW WORKERS COMPENSATION November 2014 CONTENTS SECTION 1 User Notes MISCELLANEOUS DOCUMENTS Manual Page WC 00 MASTER Master File...1 WC 03 INFO Matter Information Sheet...5 WC 03 ACCT General Account...7 WC 03 ACCTDISB General Disbursement Account...10 WC 03 BRIEF Brief to Barrister...12 WC 03 COVER File Cover...15 WC 03 FILENOTE Memo to File...19 WC 03 MEMO Office Memo...20 WC 03 STATDEC Statutory Declaration...21 SECTION 2 GENERAL LETTERS AND FACSIMILES WC 01 L1 Letter to Client...1 WC 01 L3 Letter General...3 WC 01 LA Letter to Worker/Dependant's Solicitor...5 WC 01 LR Letter to Employer/Employers Solicitor...7 WC 01 LIN Letter to Insurer/Insurer's Solicitor...9 WC 01 LB Letter to Barrister...12 WC 01 LC Letter to Workers Compensation Commission/District Court...14 WC 01 LDOC Letter to Doctor...15 WC 02 F1 Facsimile to Client...16 WC 02 F3 Facsimile General...18 WC 02 FA Facsimile to Worker/Dependant's Solicitor...20 WC 02 FR Facsimile to Employer/Employer's Solicitor...21 WC 02 FIN Facsimile to Insurer/Insurer's Solicitor...23 WC 02 FB Facsimile to Barrister...25 WC 02 FC Facsimile to Workers Compensation Commission/District Court...26 WC 02 FDOC Facsimile to Doctor...27 Softdocs (Nov 2014) 1.

2 SECTION 3 DISTRICT COURT FORMS WCX COAL DCFM8A Statement of Claim - Coal Miners Workers Comp List (Form 8A)...1 WCX COAL DCFM8B Statement of Claim in respect of death of worker (Form 8B)...10 WCX COAL DCFM8D Statement of Claim in Appln for Termination/Diminution/Redemption (Form 8D)...15 WCX COAL DCFM149 Application for Medical Panel (Form 149)...20 WCX COAL DCFM150 Certificate of Compliance (Form 150)...29 WCX COAL DCFM151 Application for Medical Panel Boilermakers Deafness (Form 151)...32 WCX COAL WC050 Schedule of Earnings...36 WCX NU FORM001 General Form...37 WCX NU FORM003A Statement of Claim...42 WCX NU FORM007A Defence...47 WCX NU FORM014 Statement of Particulars Personal Injury Proceedings...51 WCX NU FORM015 Statement of Particulars Compensation to Relatives Proceedings...56 WCX NU FORM020 Notice of Motion...58 WCX NU FORM024 Notice to Produce to Court...61 WCX NU FORM025 Subpoena to Attend to Give Evidence...64 WCX NU FORM026A Subpoena to Produce with Subpoena Notice and Declaration...66 WCX NU FORM027A Subpoena to Attend to Give Evidence and to Produce with Notice and Declaration...71 WCX NU FORM033 Notice of Discontinuance...74 WCX NU FORM040 Affidavit...76 WCX NU FORM041 Affidavit of Service...78 WCX NU FORM044 Consent Judgment/Order...80 WCX NU FORM077 Notice of Change/Appointment of Solicitor...82 WCX NU FORM080 Notice of Ceasing to Act...83 WCX NU FORMS008 Terms of Settlement...84 WCX NU FORMS008A Terms of Settlement for Industrial Deafness...85 WCX NU FORMS026 Short Minutes of Order...86 WCX NU FORMS052 Schedule of Actual and Probable Weekly Earnings...87 OTHER DOCUMENTS WC WCA010.HPT Government Information (Public Access) Act Application Form (WorkCover)...88 WC WCA015.HPT Worker's Injury Claim Form (WorkCover)...93 WC WCA020.HPT Permanent Impairment Claim Form (WorkCover) WC WCA030 Appln to WorkCover for Certification under Section 87EA(1) of the WC Act WC WCA035.HPT Application to WorkCover for Information (WCI) WC WCA040.HPT ILARS Grant Form (WIRO) WC WC010 Initial Statement of Worker WC WC012 Supplementary Statement of Worker WC WC014 Medical Report Running List WC WC055 Schedule of Expenses WC WC060 Authority to Release File WC WC070 Authority for Information WC WC072 Authority for Information from Hospital WC WC074.HPT Medicare Compensation Recovery Third Party Authority [MO021] WC WC076.HPT Medicare Compensation Recovery Bank Acct Details Collection [MO024] WC WC078.HPT Medicare Compensation Payer's EFT Details Collection [MO025] WC WC080 Authority to Receive WC WC085 Authority to Pay Legal Costs and Disbursements WC WC090.HPT Medicare Notice of Judgment or Settlement [MO022] WC WC091.HPT Medicare Request for History Statement [MO026] WC WC092.HPT Medicare Notice of Reimbursement Arrangement [MO027] WC WC093.HPT Medicare Section 23A Statement and Statutory Declaration [MO023] Softdocs (Nov 2014) 2.

3 SECTION 3 OTHER DOCUMENTS (Continued) WC WC095 Consent Orders - WCC Certificate of Determination WC WC096 WorkCover CAS - No Response Call Sheet WC WC264.HPT Centrelink Authority to Release Personal Information PI matters [SI039] WC WC265.HPT Centrelink Compensation Advice of Lump Sum Payments [SS446] WC WC267.HPT Centrelink Compensation Advice of Periodic Payments [SS445] SECTION 4 WORKERS COMPENSATION COMMISSION FORMS Party Details Information for WCC Forms...1 WC WCCF1 Application for Expedited Assessment (Form 1)...4 WC WCCF1A Application to Revoke an Interim Payment Direction (Form 1A)...12 WC WCCF1B Reply to Application for Expedited Assessment (Form 1B)...16 WC WCCF2 Application to Resolve a Dispute (Form 2)...21 WC WCCF2U Uninsured Employer Cover Sheet (Addition to Form 2 or Form 2D)...35 WC WCCF2S Section 162 Cover Sheet (Addition to Form 2 or Form 2D)...36 WC WCCF2M Multiple Employers Cover Sheet (Addition to Form 2 or Form 2D)...37 WC WCCF2A Reply to Application to Resolve a Dispute (Form 2A)...39 WC WCCF2B Application to Join a Party to Proceedings (Form 2B)...46 WC WCCF2C Application to Admit Late Documents (Form 2C)...50 WC WCCF2D Application in Respect of Death of Worker (Form 2D)...53 WC WCCF4 Certificate of Service (Form 4)...61 WC WCCF5A Application to Register a Commutation Agreement (Form 5A)...64 WC WCCF5C Application for Determination to Commute Liability (Form 5C)...70 WC WCCF6 Application to Resolve a Workplace Injury Management Dispute (Form 6)...77 WC WCCF7 Application for Assessment by an Approved Medical Specialist (Form 7)...83 WC WCCF7A Response to Appln for Assessment by an Approved Medical Specialist (Form 7A)...89 WC WCCF8 Direction for Production (Form 8)...93 WC WCCF8A Appln for Leave to Serve a Direction for Production Outside the State (Form 8A)...97 WC WCCF8_SE SEPA Notice to Producer/Witness Outside New South Wales WC WCCF8B Summons to Attend (Form 8B) WC WCCF9 Appeal Against Decision of Arbitrator (Form 9) WC WCCF9A Notice of Opposition to Appeal Against Decision of Arbitrator (Form 9A) WC WCCF10 Application to Appeal Against Decision of Approved Medical Specialist (Form 10) WC WCCF10A Notice of Opposition to Appeal Against Decision of Approved Medical Specialist (Form 10A) WC WCCF11 Direction for Access to Information and Premises (Form 11) WC WCCF11A Certificate of Service for Work Injury Damages Claim (Form 11A) WC WCCF11B Application to Cure a Defective Pre-filing Statement (Form 11B) WC WCCF11C Application for Mediation of a Work Injury Damages Claim (Form 11C) WC WCCF11D Response to Application for Mediation of a Work Injury Damages Claim (Form 11D) 142 WC WCCF11E Application to Strike Out a Pre-filing Statement (Form 11E) WC WCCF11F Notice of Opposition to Strike Out a Pre-filing Statement (Form 11F) WC WCCF13 Application for Leave to Refer a Question of Law (Form 13) WC WCCF13A Notice of Opposition to Appln for Leave to Refer a Question of Law (Form 13A) WC WCCF14A Agreement to Discontinue Proceedings (Form 14A) WC WCCF14B Election to Discontinue Proceedings (Form 14B) WC WCCF15 Appln for Assessment of Costs (under Sch 6 in force before 1 Nov 2006) (Form 15) WC WCCF15A Application for Assessment of Costs (under Sch 6 in force on 1 Nov 2006) (Form 15A)..176 WC WCCF15B Application for Assessment of Costs (under Schedule 7) (Form 15B) Softdocs (Nov 2014) 3.

4 SECTION 4 WORKERS COMPENSATION COMMISSION FORMS (Continued) WC WCCF18 Wages Schedule (Form 18) WC WCCF19 Application for Reconsideration of Commission Decision (Form 19) WC WCCF19A Notice of Opposition to Reconsideration of Commission Decision (Form 19A) WC WCCF20 Miscellaneous Application (Form 20) WC WCCFX1 Complying Agreement pursuant S66A of the Workers Compensation WC WCCFX2 Statement of Evidence by Worker WC WCCFX2W Statement of Evidence by Witness WC WCCFX3 Notice for Production WC WCCFX4 Application for Review by Insurer SECTION 6 LETTERS INITIAL LETTERS WCL WC200 Letter to Client (Applicant) requesting Information...1 WCL WC202 Letter to Client (Applicant) Advice and Instructions...2 WCL WC204 Letter to Client (Applicant) Advice re Psychological/Psychiatric Injury...6 WCL WC206 Letter to Client (Applicant) Contracting out of WID or MVA Scale...10 WCL WC208 Letter to Client enclosing Cost Agreement...11 WCL WC210 Letter to Client's Former Solicitor...12 WCL WC212 Letter to Client (Applicant) enclosing Authorities for Signature...13 WCL WC214 Letter to Client (Applicant) advising Civil Liability Costs and LPA Restrictions...14 WCL WC220 Letter to Employer requesting details of Employment...15 WCL WC222 Letter to Employer requesting Wage Records...16 WCL WC224 Letter to Employer requesting Insurance Information...17 WCL WC230 Letter to Insurer Liability Declined...18 WCL WC232 Letter to Insurer Liability Accepted...19 WCL WC240 Letter to Insurer requesting details of Payments...20 WCL WC242 Letter to Insurer follow up Where No Response...21 WCL WC244 Letter to Employer follow up Where No Response...22 WCL WC250 Letter to Centrelink requesting details of Payments...23 WCL WC280 Letter to NSW Industrial Relations request for Historical Award Information...30 WCL WC290 Letter to Client (Applicant) re Medical Process...32 WCL WC292 Letter to Client (Applicant) enclosing Statement of Evidence...33 LETTERS MEDICAL WCL WC300 Letter to Hospital request for Treatment Information...34 WCL WC310 Letter to Treating Doctor request for Medical Report...35 WCL WC320 Letter to Treating Doctor request for Updated Medical Report...36 WCL WC330 Letter to Independent Medical Examiner re Medical Legal Appointment...37 WCL WC340 Letter to Independent Medical Examiner re Refresher Medical Appointment...41 WCL WC350 Letter to Doctor repeating request for Report...43 WCL WC360 Letter to Client (Applicant) requesting Fee for Hospital/Medical Report...44 WCL WC370 Letter to Doctor enclosing Report Fee...45 WCL WC380 Letter to Doctor/Hospital requesting Itemised Account...46 WCL WC390 Letter to Client (Applicant) advising of Medical Appointment...47 WCL WC400 Letter to Client (Applicant) advising of Respondent's Medical Appointment...48 WCL WC402 Letter to Client (Applicant) advising of Approved Medical Specialist Appointment...49 WCL WC404 Letter to Insurer claiming Client Expenses...50 WCL WC406 Letter to Client (Applicant) enclosing reimbursement of Expenses...51 Softdocs (Nov 2014) 4.

5 SECTION 6 LETTERS FILING AND SERVICE WCL WC410 Letter to WCC enclosing Initial Application/Response...52 WCL WC412 Letter to WCC lodging Documents (Not Initial Application)...53 WCL WC414 Letter to WCC enclosing Documents for Lodgment...54 WCL WC420 Letter to Other Party serving Documents...55 WCL WC422 Letter to Insurer serving Application For Review...56 WCL WC430 Letter to Barrister with documents for Inclusion In Brief...57 WCL WC440 Letter to Process Server enclosing Documents for Service...58 WCL WC442 Letter to Other Party enclosing Notice for Production...59 WCL WC444 Letter General enclosing Direction for Production...60 WCL WC446 Letter to Witness enclosing Summons to Attend...61 WCL WC448 Letter to Other Party enclosing copy Notice/Direction for Production...62 WCL WC450 Letter to Client enclosing Notice/Direction for Production from Other Party...63 WCL WC453 Letter to Applicant's Solicitor serving Respondent's Reply...64 WCL WC455 Letter to WCC re Direction for Production seeking Extension of Time...65 WCL WC456 Letter to WCC re Notice for Production to consider prosecution for non production...66 WCL WC457 Letter to Other Party re Non Production of Documents...67 LETTERS CLAIMS PREPARATION WCL WC460 Letter to Client advising Application Lodged...68 WCL WC462 Letter to Client (Applicant) advising Formal Claim/Application for Review Made...69 WCL WC470 Letter to Other Party making Claim for Weekly, Medical and Lump Sum Payments...72 WCL WC472 Letter to Other Party making Claim for Lump Sum Payments...77 WCL WC474 Letter to Other Party chasing Response to Lump Sum Claim...81 WCL WC476 Letter to Barrister confirming Conference...82 WCL WC478 Letter to Client advising of Conference with Barrister...83 LETTERS HEARING WCL WC480 Letter to WCC requesting Interpreter for Teleconference...84 WCL WC482 Letter to Client advising Teleconference...85 WCL WC484 Letter to Client advising Arbitration Hearing and/or Conference...86 WCL WC485 Letter to Barrister confirming Arbitration Hearing Date WCL WC486 Letter to Barrister advising Listing Date and/or Conference...87 WCL WC488 Letter to Other Party seeking Consent to change Teleconference...88 WCL WC490 Letter to WCC seeking to change Teleconference...89 Softdocs (Nov 2014) 5.

6 SECTION 6 LETTERS SETTLEMENT WCL WC500 Letter to Client (Applicant) requesting Appointment to Discuss Settlement Offer...90 WCL WC502 Letter to Client (Applicant) advising Outcome of Approved Medical Specialist...91 WCL WC504 Letter to Client (Applicant) enclosing Medicare Claims History Statement...93 WCL WC506 Letter to Client (Applicant) enclosing Certificate of Determination...94 WCL WC510 Authority to Settle...96 WCL WC512 Authority to Accept Medical Assessment Certificate Finding...97 WCL WC520 Authority to Receive WID Settlement Monies...98 WCL WC522 Letter to Client (Applicant) confirming Resolution enclosing Complying Agreement...99 WCL WC524 Letter to Client (Applicant) confirming Resolution after Teleconference or Arbitration enclosing Complying Agreement WCL WC525 Letter to Insurer enclosing signed Complying Agreement WCL WC526 Letter to Client (Applicant) enclosing Settlement Cheque WCL WC526A Acknowledgment of Receipt of Monies WCL WC527 Letter to Other Party after AMS sending Certificate of Determination WCL WC528 Letter to Other Party enclosing Assessment of Costs WCL WC530 Letter to Client (Respondent) Assessment of Applicant's Solicitors Costs WCL WC532 Letter to Client (Applicant) follow up for Notice of Past Benefits WCL WC534 Letter to Other Party requesting Medicare Refund WCL WC536 Letter to Other Party claiming Interest on Late Payment of Settlement Monies WCL WC538 Letter to Client enclosing Final Bill WCL WC540 Letter to Doctor enclosing Payment of Account LETTERS MISCELLANEOUS WCL WC550 Letter to Client to telephone this Office to make an Appointment WCL WC552 Letter to Interpreter Service requesting booking of Interpreter WCL WC560 Letter to Medicare enclosing Request for History Statement and Authority WCL WC562 Letter to Medicare returning History Statement WCL WC564 Letter to Medicare (general) WCL WC570 Letter to Applicant's Solicitor requesting Further and Better Particulars LETTERS INDUSTRIAL DEAFNESS IND.D WCL WC600 Letter to (Applicant) Initial Advice...1 WCL WC605 Letter to Employer requesting Details of Prior Industrial Deafness Claims...3 WCL WC610 Industrial Deafness - Notice of Injury Form...4 WCL WC615 Letter to Client (Applicant) enclosing Notice of Injury Form...5 WCL WC620 Letter to Client (Applicant) advising Medical Appointment...6 WCL WC625 Letter to Ears, Nose and Throat Specialist requesting Report...7 WCL WC630 Letter to Doctor confirming Medical Appointment...8 WCL WC635 Letter to Client (Applicant) seeking Instructions to Make Claim...9 WCL WC640 Letter to Employer/Insurer making Claim...11 WCL WC645 Letter to Client (Applicant) advising Insurer Medical Appointment...14 WCL WC650 Letter to Client (Applicant) advising Loss Less than 6% Recover Report Fee...15 WCL WC655 Letter to Client (Applicant) advising No (Further) Hearing Loss (No Reimbursement Report Fee)...16 WCL WC660 Letter to Employer/Insurer serving Report (No Claim) requesting Report Fee...17 WCL WC680 Letter to Client (Applicant) after Settlement...18 Softdocs (Nov 2014) 6.

7 SECTION 6 LETTERS COAL MINES COAL WCX WC706 Letter to Process Server enclosing Documents for Service...1 WCX WC710 Letter General/Doctor enclosing Subpoena for Production...2 WCX WC716 Letter General/Doctor enclosing Subpoena to Give Evidence...3 WCX WC720 Letter to Doctor serving Subpoena to Give Evidence and Instructions...4 WCX WC722 Letter to Doctor serving Subpoena for Production and to Give Evidence...5 WCX WC726 Letter General/Doctor extending Return Date of Subpeona...6 WCX WC728 Letter to Other Party advising Documents not Produced Extending Return Date...7 WCX WC730 Letter to Other Party re Listing of Matter...8 WCX WC736 Letter to Applicant (Plaintiff) Solicitor re Listing of Matter...9 WCX WC740 Letter to Barrister advising Call-Over/Hearing Date/Conference...10 WCX WC746 Letter to Client (Plaintiff/Applicant) advising Call-Over/Hearing/Barrister Conference 11 WCX WC750 Letter to Doctor advising Hearing Date and requesting Itemised Account...12 WCX WC756 Letter General/Doctor advising new date for Return of Subpoena...13 WCX WC760 Letter to Other Party (Defendant/Respondent) re Privilege Mention Date...14 WCX WC766 Letter to Court requesting copy of Transcript...15 WCX WC770 Letter to Client (Plaintiff/Applicant) confirming Instructions...16 WCX WC776 Letter to Client (Plaintiff/Applicant) Result of Insurance Company Doctor's Tests...17 WCX WC780 Letter to Client (Plaintiff/Applicant) advising of Medical Panel Examination...18 WCX WC786 Letter to Insurer requesting Cheque for Result of Medical Panel Findings...19 WCX WC790 Letter to Client (Plaintiff/Applicant) advising Settlement at Hearing...20 Softdocs (Nov 2014) 7.

8 ALPHABETICAL TABLE OF FORMS Section.Page A Acknowledgment of Receipt of Monies WC526A S6.109 Affidavit (UCPR) NU FORM040 S3.76 Affidavit of Service (UCPR) NU FORM041 S3.78 Agreement to Discontinue Proceedings (WCC Form 14A) WCCF14A S4.163 Appeal Against Decision of Approved Medical Specialist (WCC Form 10) WCCF10 S4.120 Appeal Against Decision of Arbitrator (WCC Form 9) WCCF9 S4.105 Application for Assessment by an Approved Medical Specialist (WCC Form 7) WCCF7 S4.83 Application for Assessment of Costs (under Sch 6 before 1 Nov 2006) (WCC Form 15) WCCF15 S4.171 Application for Assessment of Costs (under Sch 6 after 1 Nov 2006) (WCC Form 15A) WCCF15A S4.176 Application for Assessment of Costs (under Sch 7) (WCC Form 15B) WCCF15B S4.183 Application for Compensation and/or Expenses (VCT) VCT_AP03 S5.6 Application for Compensation by Family Members of a Homicide Victim (VCT) VCT_AP05 S5.20 Application for Counselling by Family Members of a Homicide Victim (VCT) VCT_AP04 S5.16 Application for Determination to Commute Liability (WCC Form 5C) WCCF5C S4.70 Application for Expedited Assessment (WCC Form 1) WCCF1 S4.4 Application for Funeral Expenses (VCT) VCT_AP07 S5.29 Application for Initial Counselling (VCT) VCT_AP01 S5.1 Application for Leave to Refer a Question of Law (WCC Form 13) WCCF13 S4.153 Application for Leave to Serve A Direction for Production Outside the State (WCC Form 8A) WCCF8A S4.97 Application for Mediation of a Work Injury Damages Claim (WCC Form 11C) WCCF11C S4.139 Application for Medical Panel (DC Form 149) DC DCFM149 S3.20 Application for Medical Panel Boilermakers Deafness (DC Form 151) DC DCFM151 S3.32 Application for Reconsideration of Commission Decision (WCC Form 19) WCCF19 S4.191 Application for Review by Insurer WCCFX4 S4.218 Application in Respect of Death of Worker (WCC Form 2D) WCCF2D S4.53 Application to Admit Late Documents (WCC Form 2C) WCCF2C S4.50 Application to Cure a Defective Pre-filing Statement (WCC Form 11B) WCCF11B S4.135 Application to Join a Party to Proceedings (WCC Form 2B) WCCF2B S4.46 Application to Register a Commutation Agreement (WCC Form 5A) WCCF5A S4.64 Application to Resolve a Dispute (WCC Form 2) WCCF2 S4.21 Application to Resolve a Workplace Injury Management Dispute (WCC Form 6) WCCF6 S4.77 Application to Revoke an Interim Payment Direction (WCC Form 1A) WCCF1A S4.12 Application to Strike Out a Pre-filing Statement (WCC Form 11E) WCCF11E S4.144 Application to WorkCover for Certification under Section 87EA(1) of the WC Act 1987 WCA030.HPT S3.108 Application to WorkCover for Information (WCI) WCA035.HPT S3.173 Authority for Information WC070 S3.121 Authority for Information from Hospital WC072 S3.122 Authority to Accept Medical Assessment Certificate Finding WC512 S6.97 Authority to Pay Legal Costs and Disbursements WC085 S3.127 Authority to Receive WC080 S3.126 Authority to Receive WID Settlement Monies WC520 S6.98 Authority to Release File WC060 S3.120 Authority to Settle WC510 S6.96 Softdocs (Nov 2014) 8.

9 ALPHABETICAL TABLE OF FORMS Section.Page C Centrelink Authority to Release Personal Information PI matters [SI039] WC264.HPT S3.154 Centrelink Compensation Advice of Lump Sum Payments [SS446] WC265.HPT S3.146 Centrelink Compensation Advice of Periodic Payments [SS445] WC267.HPT S3.150 Certificate of Compliance DCFM150 S3.29 Certificate of Service (WCC Form 4) WCCF4 S4.61 Certificate of Service for Work Injury Damages Claim (WCC Form 11A) WCCF11A S4.133 Claim Form - Permanent Impairment (WorkCover) WCA020.HPT S3.100 Claim Form - Worker's Injury (WorkCover) WCA015.HPT S3.93 Complying Agreement pursuant S66A of the Workers Compensation 1987 (WCC) WCCFX1 S4.208 Consent Orders - Certificate of Determination (WCC) WC095 S3.141 Consent Judgment/Order (UCPR) NU FORM044 S3.80 D Defence (UCPR) NU FORM007A S3.47 Direction for Access to Information and Premises (WCC Form 11) WCCF11 S4.130 Direction for Production (WCC Form 8) WCCF8 S4.93 E Election to Discontinue Proceedings (WCC Form 14B) WCCF14B S4.167 G General Form (UCPR) NU FORM001 S3.37 Government Information (Public Access) Act Application Form (WorkCover) WCA010.HPT S3.88 I ILARS Grant Form WCA040.HPT S3.156 M Medical Report Running List WC014 S3.117 Medicare Compensation Payer's EFT Details Collection [MO025] WC078.HPT S3.125 Medicare Compensation Recovery Bank Acct Details Collection [MO024] WC076.HPT S3.124 Medicare Compensation Recovery Third Party Authority [MO021] WC074.HPT S3.123 Medicare Notice of Judgment or Settlement [MO022] WC090.HPT S3.128 Medicare Notice of Reimbursement Arrangement [MO027] WC092.HPT S3.137 Medicare Request for History Statement [MO026] WC091.HPT S3.134 Medicare Section 23A Statement and Statutory Declaration [MO023] WC093.HPT S3.140 Miscellaneous Application WCCF20 S4.201 Multiple Employer Cover Sheet (Addition to WCC Form 2) WCCF2M S4.37 N Notice for Production WCCFX3 S4.215 Notice of Ceasing to Act (UCPR) NU FORM080 S3.83 Notice of Change/Appointment of Solicitor (UCPR) NU FORM077 S3.82 Notice of Discontinuance (UCPR) NU FORM033 S3.74 Notice of Injury - Industrial Deafness WC610 S6.IND 4 Notice of Motion (UCPR) NU FORM020 S3.58 Notice of Opposition to Appeal against Decision of Approved Medical Specialist (WCC Form 10A) WCCF10A S4.126 Notice of Opposition to Appeal Against Decision of Arbitrator (WCC Form 9A) WCCF9A S4.113 Notice of Opposition to Application for Leave to Refer a Question of Law (WCC Form 13A) WCCF13A S4.158 Notice of Opposition to Reconsideration of Commission Decision (WCC Form 19A) WCCF19A S4.196 Softdocs (Nov 2014) 9.

10 ALPHABETICAL TABLE OF FORMS Section.Page Notice of Opposition to Strike Out a Pre-filing Statement (WCC Form 11F) WCCF11F S4.149 Notice to Produce to Court (UCPR) NU FORM024 S3.61 R Reply to Application for Expedited Assessment (WCC Form 1B) WCCF1B S4.16 Reply to Application to Resolve a Dispute (WCC Form 2A) WCCF2A S4.39 Request for Further Approved Counselling (VCT) VCT_AP02 S5.5 Response to Application for Mediation of a Work Injury Damages Claim (WCC Form 11D) WCCF11D S4.142 Response to Application for Medical Assessment (WCC Form 7A) WCCF7A S4.89 S Schedule of Actual and Probable Weekly Earnings (UCPR) NU FORMS052 S3.87 Schedule of Earnings DC WC050 S3.36 Schedule of Expenses WC055 S3.119 SEPA Notice to Producer/Witness Outside New South Wales (WCC) WCCF8_SE S4.101 Short Minutes of Order (UCPR) NU FORMS026 S3.86 Statement of Claim (UCPR) NU FORM003A S3.42 Statement of Claim - Coal Miners Workers Comp List (DC Form 8A). DC DCFM8A S3.1 Statement of Claim - Application for Termination Diminution or Redemption (DC Form 8D) DC DCFM8D S3.15 Statement of Claim in respect of death of worker (DC Form 8B). DC DCFM8B S3.10 Statement of Evidence by Worker (WCC) WCCFX2 S4.213 Statement of Evidence by Witness (WCC) WCCFX2W S4.214 Statement of Particulars Personal Injury Proceedings (UCPR) NU FORM014 S3.51 Statement of Particulars Compensation to Relatives Proceedings (UCPR) NU FORM015 S3.56 Statement of Worker, Initial WC010 S3.115 Statement of Worker, Supplementary WC012 S3.117 Subpoena to Attend to Give Evidence (UCPR) NU FORM025 S3.64 Subpoena to Attend to Give Evidence and to Produce with Notice and Declaration (UCPR) NU FORM027A S3.71 Subpoena to Attend to Produce with Subpoena Notice and Declaration (UCPR) NU FORM026A S3.66 Summons to Attend (WCC Form 8B) WCCF8B S4.102 T Terms of Settlement (UCPR) NU FORMS008 S3.84 Terms of Settlement for Industrial Deafness (UCPR) NU FORMS008A S3.85 W Wages Schedule (WCC Form 18) WCCF18 S4.188 WorkCover CAS - No Response Call Sheet WC096 S3.143 Softdocs (Nov 2014) 10.