Workmen’s Compensation Regulations

WORKMEN’S COMPENSATION REGULATIONS PUBLISHING DETAILS Revised under the authority of the Law Revision Law (19 of 1975). The Workmen’s Compensation Regulations, 1965 made the 22nd July, 1965. Revised this 16th day of June , 1998 Regulation PART I - INTRODUCTORY PART II - PROCEDURE ON MAKING APPLICATION FOR PART III - MEMORANDUM OF AGREEMENT PART IV - APPLICATION FOR REVIEW OR REDEMPTION OF HALF-MONTHLY PAYMENT AND FOR ORDER WHERE WORKMAN UNDER LEGAL DISABILITY PART V - PAYMENT OF COMPENSATION INTO COURT PART VI - MEDICAL EXAMINATION OF WORKMAN PART VII - ORDER AND EXECUTION PART VIII - MISCELLANEOUS FORMS Regulation 2 PART I - INTRODUCTORY Citation These regulations may be cited as the Workmen’s Compensation Regulations (1998 Revision). Definitions In these regulations — “Clerk” means the Clerk of the Court or any person performing the duties of the Clerk; “Court’’ means the Grand Court; and “Form” means a form in the Schedule hereto. PART II - PROCEDURE ON MAKING APPLICATION FOR Applications (1) Any application referred to in section 28 shall be filed with the Clerk, and shall, unless the Court otherwise directs, be in Form 1 or 2 as the case may be. (2) Where both the principal as defined by the Law and a contractor with him are alleged to be liable to pay compensation under the Law, the rules of the Court applicable to joinder of parties shall apply. (3) An application on behalf of dependants of a deceased workman for the settlement of any question arising out of an accident resulting in the death of that workman may be made by the legal personal representative, if any, of the deceased workman on behalf of such dependants, or by the dependants themselves. (4) If there is any conflict of interest between the dependants themselves, or if any dependants when invited to do so neglect or refuse to join in an application, the application may be made by or on behalf of some only of such dependants, the other dependants in either case being named as respondents. (5) In any case in which the amount of compensation payable as the result of the death of a workman has been agreed upon or ascertained, but any question arises as to who are dependants, or as to the amount payable to any dependent, an application for the settlement of such question may be made either by the legal personal representative, if any, of the deceased workman on behalf of the dependants or any of them, or by such dependants or any of them, against the other dependants, and the persons claiming or who may be entitled to claim to be dependants, but as to whose claim to rank as such a question arises; or the application may be made by the persons claiming to be dependants, but as to whose claim to rank as such a question arises, or any of them, against the legal personal representative, if any, of the deceased workman, and the dependants, and such of the persons claiming or who may be entitled to claim to be dependants as are not applicants. (6) If the employer has paid the agreed or ascertained amount of compensation into Court, it shall not be necessary to make him a respondent, and if made a respondent, the Court may direct that all further proceedings against him be stayed. (7) Where the sole question for the determination of the Court is the amount of the funeral expenses of a deceased workman who has left no dependants, the application may be made by the legal personal representative, if any, of the deceased workman, or by the person to whom any such expenses are due. Regulation 4 (8) The Court may, at any time, direct that an infant shall appear either as applicant or respondent in the same manner as if he were of full age. (9) In subregulation (4) — “dependants” include persons who claim or may be entitled to claim to be dependants, but as to whose claim to rank as dependants any question arises. Procedure where indemnity claimed Where the respondent claims that if compensation is recovered against him he will be entitled to be indemnified under the Law by a person not a party to the proceedings (hereinafter referred to as the third party), he shall, within seven days after being served with the copy of the application, file a notice of such claim with the Clerk, and the Clerk shall thereupon cause a copy of the notice of such claim together with a notice in Form 3 to be served on the third party, and the third party shall file a written statement dealing with the matter raised in the application for compensation or with the claim for indemnity or both within seven days from the service of the copy of the notice thereof or such further time as the Court may allow. Procedure where claim admitted If the third party admits the claim, he shall at any time before the first hearing — (a) where the application is made by an injured workman — (i) file with the Clerk a notice that he submits to an order for the payment of a half-monthly sum, to be specified in such notice; or (ii) file with the Clerk a notice that he submits to an order for the payment of a lump sum, to be specified in the notice, and pay such sum into Court; or (b) where the application is made by or on behalf of the dependants of a deceased workman, or for the settlement of the sum payable in respect of the funeral of a deceased workman, who leaves no dependants, file with the Clerk a notice that he admits liability, and pay into Court such sum of money as he considers sufficient to cover his liability in the circumstances of the case. Failure of respondent or third party to file statement If the third party fails to file a written statement dealing with the claim against him within the prescribed time or within the time fixed by the Court on an application to enlarge the time, he shall be taken to admit the claim. Regulation 7 Third party procedure where employer is the applicant Regulations 4 to 6 shall, with the necessary modifications, apply to a case in which an employer is the applicant and claims to be entitled to indemnity against any person not a party to the proceedings. PART III - MEMORANDUM OF AGREEMENT Form of memorandum (1) Memoranda of agreement sent to the Clerk of the Court under section 17(4), shall be in as close conformity as the circumstances of the case permit with Form 4 or 5 as the case may be. (2) Every such memorandum shall contain the like particulars as would have been required if the memorandum had been an application for compensation under these regulations. Notice to parties interested of memorandum having been received On receipt of a memorandum and the necessary copies thereof the Clerk shall cause to be served a copy on every party interested together with a notice in Form 6 requesting such party to inform him within seven days from the date of the notice whether the memorandum is genuine, whether he disputes its genuineness or whether the recording of the memorandum is objected to and, if so, on what grounds. Where genuineness of memorandum disputed or objection made by

If — (a) any party interested disputes the genuineness of the memorandum (for example, by alleging that no such agreement has in fact been entered into, that the terms of the agreements are not correctly stated in the memorandum, that the agreement is no longer subsisting or enforceable or that it is not enforceable by reason of its having been entered into under a mutual mistake or obtained by fraud or undue influence or other improper means); or (b) where a workman seeks to record a memorandum of agreement between his employer and himself, the employer proves by an affidavit that the workman has, in fact, returned to work, and is earning wages as he did before the accident, and objects to the recording of the memorandum, the party so disputing or objecting shall, within the time prescribed in regulation 9, file with the Clerk, in case of a dispute under paragraph (a), a notice in Form 7 stating the grounds on which the genuineness of the Regulation 11 memorandum is disputed or, in case of an objection under paragraph (b), the affidavit stating the grounds on which the recording thereof is objected to. Notice of dispute or objection

On receipt of any notice or affidavit under regulation 10, the Clerk shall cause to be served a copy thereof on every other interested party together with a notice in Form 8 informing every such party that the memorandum will not be recorded except by order of the Court. Subsequent proceedings

(1) On receipt of any notice under regulation 11, any interested party may apply to the Court to order the memorandum to be recorded. (2) Where any such application is made the Clerk shall refer to the Court the memorandum and all other documents filed in connection therewith, and the Court shall fix a day on which notice shall be given to the parties for the determination of the matter. (3) At any time during the hearing of an application to record a memorandum, the Court may, with the consent of all parties interested, amend the memorandum. (4) Upon the hearing of any such application the Court shall determine the matter in controversy between the parties, and may confirm or rectify the memorandum of agreement and direct the Clerk to record it or may make such other order as may seem just. Application for cancellation of agreement

(1) An application for cancellation of an agreement under section 17(2) shall be in Form 9. (2) The applicant shall, in an affidavit accompanying the application, state the facts necessary to establish that he is an interested person, verify the grounds on which cancellation of the agreement is sought and, if any money has already been paid under the agreement, he shall also state the particulars of the amount and date of every payment. PART IV - APPLICATION FOR REVIEW OR REDEMPTION OF HALF-MONTHLY PAYMENT AND FOR ORDER WHERE WORKMAN UNDER LEGAL DISABILITY When application may be made without medical certificate

Any application of the nature referred to in section 7 shall be in Form 10 and may be made without a medical certificate — Regulation 15 (a) by the employer, on the ground that, since the right to compensation was determined, the workman’s wages have increased; (b) by the workman, on the ground that, since the right to compensation was determined, his wages have diminished; by the workman, on the ground that the employer, having commenced to pay compensation, has ceased to pay the same, notwithstanding the fact that there has been no change in the workman’s condition such as to warrant such cessation; (d) by the employer, on the ground that the workman has ceased, since the right to compensation was determined, to be a minor; (e) either by the employer or the workman, on the ground that the determination of the rate of compensation for the time being in force was obtained by fraud, undue influence or other improper means; or (f) either by the employer or the workman, on the ground that in the determination of compensation there is a mistake or error apparent on the face of the record. Procedure on application for review

If, on examining an application for review by an employer in which the reduction or discontinuance of half-monthly payments is sought, it appears to the Court that there is reasonable ground for believing that the employer has a right to such reduction or discontinuance, the Court may, at any time, issue an order withholding the half-monthly payments in whole or in part pending its decision on the application. Procedure on application for redemption

(1) Any application of the nature referred to in section shall be in Form 10. (2) Where application is made to the Court under section 8 for the redemption of a right to receive half-monthly payments by the payment of a lump sum upon the amount of which the parties are unable to agree, the Court shall form an estimate of the probable further duration of the incapacity, and shall award a sum equivalent to the total of the half-monthly payments which would be payable for the period during which it estimates that the incapacity will continue, less one-half percent of that total for each month comprised in that period: Provided that fractions of a cent included in the sum so computed shall be disregarded. (3) When, in any case to which subregulation (2) applies, the Court is unable to form an approximate estimate of the probable further duration of the incapacity, the Court may, from time to time, postpone a decision on the application for a period not exceeding two months at any one time. Regulation 17 Application for order where workman under legal disability

An application under section 10(6) for an order that a half-monthly payment payable to a workman under any legal disability shall, during the disability, be paid to any dependent or other person may be made either by the person liable to make such payment or by or on behalf of the workman entitled to such payment. The application shall be in Form 11 and shall be served on every interested party. Application for variation of order

An application for the variation of an order of the Court under section 10(7) may be made by or on behalf of any person interested. The application shall be in Form 12 stating the circumstances under which the application is made and the relief or order which the applicant claims, and shall be served on every other interested party. PART V - PAYMENT OF COMPENSATION INTO COURT Payment into court generally

Compensation shall be paid into Court — (a) under an order of the Court directing a specific sum to be paid in as (b) under an agreement between an employer or other person liable to pay compensation and a workman or the dependants of a workman according to the tenor thereof; or pursuant to a claim for compensation made out of Court, or to an application for compensation, against an employer or other person liable to pay the same who admits liability, or denies liability but is willing to pay an amount in settlement of the claim. Payment into court under section 10(1)

(1) An employer paying compensation into Court under section 10(1) shall furnish therewith a statement in Form 13. (2) If, in the said statement, the employer indicates that he desires to be made a party to the distribution proceedings, the Court shall, before allotting the sum deposited as compensation, afford to the employer an opportunity of establishing that the person to whom it proposes to allot such sum is not a dependent of the deceased workman, or as the case may be, that no one of such persons is a dependent. (3) Any dependent, whether a notice under of section 10(5) has been published or not, may apply to the Court for the payment out or distribution of any sum so deposited. Regulation 21 (4) The statement of disbursements to be furnished on application by the employer under section 10(5) shall be in Form 14. Publication of list of payments into Court

The Clerk shall cause to be displayed in a prominent position outside the Court an accurate list of deposits paid into Court under section 10(1) together with the names and addresses of the depositors and of the workmen in respect of whose death the deposits have been made. Procedure where no compensation deposited

(1) Where a dependent of a deceased workman claims that compensation is payable in respect of the death of the workman and no compensation has been deposited under section 10(1) in respect thereof, the dependent may apply to the Court for the issue of an order requiring the employer to deposit compensation in accordance with the aforesaid subsection: Provided that no such application shall be entertained unless the applicant proves by affidavit that such compensation has become payable and that he has requested the employer to deposit the compensation and that the employer has refused or omitted to do so, and such affidavit shall contain the names and addresses of all the total and partial dependants of the deceased. (2) The Court may, at any time, cause notice to be given in such manner as the Court thinks fit to all or any of the dependants of the deceased workman who have not joined in the application, requiring them, if they desire to join therein, to appear before the Court on a date specified in this behalf; and if any dependent to whom such notice has been given fails to appear and to join in the application on the date specified in the notice, he shall not be permitted thereafter to claim that the employer is liable to deposit compensation unless he satisfies the Court that he was prevented by any sufficient cause from appearing when the case was called for hearing. (3) If, after completing the inquiry into the application, the Court issues an order requiring the employer to deposit compensation under section 10(1), nothing in subregulation (2) shall be deemed to prohibit the allotment of any part of the sum deposited as compensation to a dependent of the deceased workman who failed to join in the application. Payment into Court under section 10 (2) and (3)

An employer paying compensation into Court under section 10(2) or (3) shall furnish therewith a statement in Form 15. Regulation 24 Money paid into Court shall be deposited into bank to be approved by Governor

Any money paid into Court shall be deposited in a bank to be approved of by the Governor in the name of “Grand Court (Workmen’s Compensation)” and the account shall be operated in the same manner as and under the rules and regulations governing suitors’ moneys; except that a separate ledger, cash book and receipt book shall be used in respect of such accounts. Right of employer to present memorandum when notice given

(1) Any employer to whom notice of an accident has been given may, at any time, notwithstanding the fact that no claim for compensation has been made in respect of such accident, present to the Clerk a memorandum, supported by an affidavit made by himself or by any other person having knowledge of the facts stated in the memorandum, embodying the results of any investigation or inquiry which has been made into the circumstances or cause of the accident. (2) A memorandum presented under this regulation shall be recorded by the Clerk. PART VI - MEDICAL EXAMINATION OF WORKMAN Workman to submit to medical examination in accordance with regulations

A workman who is required under section 14(1) to submit himself for medical examination shall do so in accordance with the regulations contained in this Part. Examinations on premises

When such workman is present on the employer’s premises, and the employer offers to have him examined free of charge by a medical practitioner who is so present, the workman shall submit himself for examination forthwith. Examination in other cases

In cases to which regulation 27 does not apply, the employer may, subject to section 14(3) — (a) send the medical practitioner to the place where the workman is residing for the time being, in which case the workman shall submit himself for medical examination on being requested to do so by the medical practitioner; or (b) send to the workman an offer in writing to have him examined free of charge by a medical practitioner, in which case the workman shall submit himself for medical examination at the employer’s premises or at such other place in the vicinity as is specified in such offer and at such time as is so specified: Regulation 29 Provided that — (i) the time so specified shall not, save with the express consent of the workman, be between the hours of 7 p.m. and 6 a.m. and (ii) in any case where the workman’s condition renders it impossible or inadvisable that he should leave the place where he is residing for the time being, he shall not be required to submit himself for medical examination save at that place. Extended application of regulations 27 and 28

Regulations 27 and 28 apply to any workman receiving half-monthly payments who is required by his employer under section 15 to submit himself to medical examination. Examination after suspension of right to compensation

If a workman whose right to compensation has been suspended under section 14(4) subsequently offers himself for medical examination, his examination shall take place on the employer’s premises or at such other place in the vicinity as may be fixed by the employer and at a time to be fixed by the employer not being, save with the express consent of the workman, more than seventy-two hours after the workman has so offered himself. Medical treatment of workman

The medical treatment to which a workman may be required to submit himself under section 14 shall include any treatment at or in a hospital or other institution in which the workman may be conveniently and efficiently treated for the personal injury which arose out of and in the course of his employment. PART VII - ORDER AND EXECUTION Payment of compensation by instalments

The Court may direct that any lump sum payable as compensation be paid into Court by instalments at such times as may be fixed by the Court. Execution to enforce payment of compensation

(1) Where, under regulation 22, the Court has made an order requiring the employer or other person liable to pay compensation under section 10(1), and the employer or such other person fails or neglects to do so, execution may be issued for the recovery of the amount of the compensation in the same manner as execution is issued in the Grand Court and with the like effect without any further leave of the Court. Regulation 34 (2) Where a party liable to pay compensation into Court under section 10(2) has made default in payment of the amount, the party entitled to such compensation may apply to the Court for leave to issue execution against the goods of the party in default. (3) An application for leave to issue execution shall be made under any rules applicable to an application for leave to issue execution in civil proceedings in the Court. (4) Nothing herein contained shall operate to prevent the Court from directing in its order that execution shall issue for the recovery of the amount of any compensation thereby ordered to be paid, and, if the Court so directs, execution shall issue without any application under regulation 22 for the deposit of compensation, or under this regulation for leave to issue execution. (5) Execution may be issued without leave of the Court against any party liable to make a half-monthly payment to a workman under any order or recorded memorandum of agreement, but if the party so liable file with the Clerk an application for the review of the half-monthly payment alleging that the incapacity has wholly or partially ceased, execution shall not issue until that application is disposed of by the Court: Provided that the Court may direct that execution shall be stayed pending the disposal of the application for review only upon terms that the party liable make payment into Court or otherwise of every half-monthly payment which may become due and payable pending the determination of the application. Enforcement by judgment summons

Where proceedings by way of judgment summons are taken against a party liable to pay compensation or costs under any order of the Court or any recorded memorandum of agreement, who has made default in payment of the amount of compensation, or where payment is to be made by instalments, of any instalment, the rules for the time being in force as to judgment summonses in the Court shall, with any necessary modifications, apply to such proceedings. Proceedings as against a company or firm

Where parties liable to pay compensation or costs are a company or firm the Rules of Court in civil proceedings applicable to execution or to a judgment summons against a company or firm shall apply. PART VIII - MISCELLANEOUS Forms

The forms in the Schedule shall be used in all cases to which they are applicable with such amendments as may be necessary. Regulation 37 Proceedings and service of documents where Crown a party

(1) In any proceedings under the Law or regulations arising out of an injury to a workman employed by or under the Crown, in which, if the employer were a private person, such employer would be a necessary party, the head of the department by, in or under which the workman was employed, shall, under his or their official title as representing the Crown, be made the necessary party. (2) In any such case, any proceeding, document or notice to be served on the head of the department may be served on the head of the department personally or by being left at his office with some person employed therein. Copies of documents filed

Where any document is to be filed, there shall be filed with the original document as many copies of the document as there are persons on whom copies of the document are to be served, and in addition any necessary copies for the return of service and for the use of the Court. Service of document

(1) Subject to these regulations, any proceeding, document or notice to be served under the Law or regulations may be served — (a) in the manner provided for the service of a summons issued by the Court; or (b) in accordance with any law, rule or regulation specifically providing the mode of service in any particular case. (2) A bailiff or assistant bailiff of the Court may serve any process or effect any execution required under the Law or regulations, and such service or execution shall be subject to all the rules and regulations governing the service or process or execution and of the tariff of fees for the time being in force, save as in the Law or regulations may be specifically provided. (3) Where proceedings are taken by a workman against the managing committee of a club as an employer, service or notice of any documents or proceedings shall be valid and sufficient if served on or given to a member of such committee or its secretary and on the club premises in such manner as would be valid and sufficient if he were the sole employer. Applications

(1) All persons whose presence at the hearing of any application may be necessary to enable the Court effectively and completely to adjudicate upon and settle all the questions involved shall, unless the Court otherwise directs, be made parties to the application and every such person shall be served with a copy of the application at least ten clear days before the hearing of the application. Regulation 41 (2) The Court may, whether or not an affidavit is required to be filed in support of an application, hear evidence viva voce in order to determine any question involved in any application made under these regulations. Masters, seamen and apprentices

In any proceeding for the determination of any question arising out of an accident to any master, seaman or apprentice under section 25 — (a) the claim for compensation shall state — (i) in the case of a death of a master, seaman or apprentice, the date at which news of the death was received by the claimant; or (ii) in the case of a master, seaman or apprentice, lost with his ship, the date at which his ship was lost or is deemed to have been lost; (b) the application to determine compensation shall be in Forms 1 and 2 with the necessary modifications, and there shall be added to the particulars therein the name of the ship or vessel on which the deceased workman was employed at the time of the accident, and its port of registry, and if not registered in the Islands, the name of the owner, managing owner or manager, and his residence or principal place of business if the same is in the Islands; it shall be sufficient to describe the owners of the ship as “the owners of Court as to the names of partners shall with the necessary modifications apply to the disclosure of names of such owners; and (d) subject to paragraph (a) of section 25(1) as to service of the notice of accident and the claim for compensation, any document, notice or proceeding to be served on the owners of a ship shall be deemed sufficiently served if served on the managing owner or manager for the time being of the ship, or (except where the master is claiming compensation) on the master of the ship; and section 696(1) of the Merchant Shipping Act, 1894 of the United Kingdom, shall apply to service on the master of the ship, and where the master is claiming compensation, and there is no managing owner of the ship, service may be effected in accordance with paragraph (c) of the said subsection. Signature on document

Any application to the Court or other document which is to be signed by the applicant may be signed by his attorney-at-law. Orders

An Order of the Court shall be in Form 16, 17 or 18 as is appropriate to the circumstances of the case, with any necessary variation. UK Act Regulation 44 Appointment of medical referee to report

(1) The Court may, before or after the institution of any legal proceedings and on or without the application of any interested party, refer to a medical referee for a report thereon any matter which seems material to any question arising out of an accident in which compensation is or might be claimed, and the Court shall make such order as to the payment of the costs of such report as under all the circumstances it may deem just. (2) When any matter is so referred the Court may order the injured workman to submit himself for examination by the medical referee, and it shall be the duty of the workman, on being served with such order, to submit himself for examination accordingly, and the Court shall make such order as to the payment of the costs of such examination as to the Court may seem just. (3) If a workman, on being so ordered, refuses to submit himself for examination by a medical referee to whom the matter has been so referred or in any way obstructs the same, his right to compensation and to take or prosecute any proceedings under the Law or regulations shall be suspended until such examination has taken place or such obstruction has ceased. (4) The Court may accept as prima facie evidence of the facts therein stated, the written report of a medical referee upon the physical condition of the workman, or upon any other question arising out of an accident which has been referred to him for a report. Any party to the proceeding may require the attendance of the medical referee for oral examination but that party shall be liable in the first instance to provide and pay the cost of the attendance in Court of the medical referee, pending decision by the Court as to which party shall be liable eventually to pay such costs. Statement of wages to be furnished by employer

(1) Where any proceeding is taken or is about to be taken for the determination of any question arising out of an accident in which compensation is or might be claimed, the employers shall, if required by the workman, furnish the workman, within ten days from the date of requisition, with a statement showing — (a) the total wages which have fallen due for payment to the workman by the employer in the last twelve months, where the workman has been employed during a continuous period of not less than twelve months immediately preceding the accident; or (b) the total wages earned in respect of the last continuous period of service, where that service is of less than twelve months duration immediately preceding the accident. Regulation 46 (2) A period of service shall, for the purposes of this subregulation, be deemed to be continuous which has not been interrupted by a period of absence from work exceeding fourteen days. Service of copy of answer on applicant

(1) The respondent shall, within five days of the day on which he lodges with the Clerk the written answer referred to in section 29(2), serve on every applicant a true copy of such answer: Provided that where two or more applicants are represented by the same attorney-at-law it shall not be necessary to serve more than one copy of the answer on the dependants so represented. (2) Service of the answer shall be effected by delivering the same to the applicant or applicants or to his or their attorney-at-law personally, or by leaving it at the address of the applicant or applicants or to his or their attorney-at-law as stated in the application with some person there residing or employed or if no such person is known or found there, by leaving it at the said address, in some conspicuous place, or by registered post to the said address, and in the latter case service shall be deemed to have been effected forty-eight hours after the time of posting in any Post Office in the Islands. Exemption from Court fees

No Court fees shall be payable by any party in respect of any proceedings under the Law prior to an order awarding compensation: Provided that a bailiff of the Court shall be paid for any service he is called upon to perform under the Law and regulations at the same rates and in the same manner as he would be paid for the corresponding service if performed under the Grand Court Law (1995 Revision) and the Rules made thereunder. Costs

Any costs of or incident to any proceedings for the determination of any question arising out of an accident to a workman shall be awarded in accordance with any scale prescribed under the Grand Court Law (1995 Revision) or any Rules made thereunder. Application of Rules of Court

Where no provision is made by these regulations as to the practice and procedure to be observed with respect to any matter or proceeding in the Court for the determination of any question arising out of an accident, the rules applicable to actions in the civil jurisdiction of the Court shall mutatis mutandis apply. FORMS Form 1 Application by workman or by employer to determine compensation. The applicant, a workman, is employed by (a contractor with) the or The applicant, is the employer of the abovenamed respondent, a workman who sustained personal injury by accident arising out of and in the course of his employment on the day of , 19 , at and applies herein for the determination of the questions hereinafter stated under the Workmen’s Compensation Law (1996 Revision). Place of business, and nature of business of respondent. Nature of employment of workman at time of accident, and whether employed under opposite party or under a contractor with him. (If employed under a contractor who is not a respondent, name and place of business of contractor to be stated). Date and place of accident, nature of work on which workman was then engaged, nature of accident and cause of injury. Nature of injury. Particulars of incapacity for work, whether total or partial, and estimated duration of incapacity. Monthly wages during the twelve months previous to the injury, if the applicant has been so long employed under the employer by whom he was immediately employed, or if not, during any less period during which he has been so employed. Monthly amount which the applicant is earning or is able to earn in some suitable employment or business after the accident. Payment, allowance or benefit received from employer during the period of incapacity Amount claimed as compensation. 10. Date of service of statutory notice of accident on employer, and whether given before workman voluntarily left the employment in which he was injured. (A copy of the notice to be annexed). 11. If notice not served, reason for omission to serve same. 12. Date of claim for compensation. 13. Name of ship of which applicant was master, seaman or apprentice at time of accident, and port of registry (See regulation 41). (If application is made by an employer insert here statement required by section 28(2)). Questions for the determination of the Court- (a) whether the applicant (or respondent as the case may be) is a workman within the meaning of the Law; (b) whether the accident arose out of and in the course of the workman’s employment; whether the amount of compensation claimed is due, or any part of that amount; (d) whether the respondent is liable to pay such compensation as is due; and (e) etc., (as required). To I do hereby require you to lodge with me, the undersigned Clerk of the Court, within seven days after service hereof, a written answer containing a concise statement of the extent and grounds of opposition, if any, to the above application. And further take notice that the hearing of this application is fixed for the day of , 19 at the abovenamed Court and that if you fail to lodge such answer or to appear at that time and place, an order may be made against you in default. Form 2 Application by or on behalf of dependants of deceased workman or by employer to determine compensation. The applicant is the legal personal representative (or the dependent) of a workman employed by (a contractor with) the respondent or The applicant was the employer of a workman who sustained personal injury by accident arising out of and in the course of his employment on the day of , 19 at in resulting in his death, and applies herein for the determination of the question hereinafter stated, under the Workmen’s Compensation Law (1996 Revision). Name and late address of deceased workman. Place of business, and nature of business of employer from whom compensation is claimed. Nature of employment of deceased at time of accident, and whether employed under the alleged employer or under a contractor with him. (If employed under a contractor who is not a respondent, name and place of business of contractor to be stated). Date and place of accident, nature of work on which deceased was then engaged and nature of accident and cause of injury. Nature of injury to deceased and date of death (or date when ship was lost or deemed to have been lost). Monthly wages during the twelve months previous to the injury, if the applicant has been so long employed under the employer by whom he was immediately employed, or if not, during any less period during which he has been so employed. Amount of the half-monthly payments, if any, made to deceased under the Law and of any lump sum paid in redemption thereof. Character in which applicant applies for compensation, i.e., whether as legal personal representative of deceased or as a dependent, and if as a dependent particulars showing how he is so. Particulars as to dependants of deceased by whom or on whose behalf the application is made, giving their names and addresses, descriptions and occupations, if any, and their relationship to the deceased, and if infants, their respective ages, and stating whether they were wholly or partially dependent on the earnings of the deceased at the time of his death. 10. Particulars as to any person claiming, or who may be entitled to claim to be dependants, but as to whose claim a question arises, and who are therefore made respondents, with their names, addresses, descriptions and occupations, if any. 11. Particulars of amount claimed as compensation, and of the manner in which the applicant claims to have such amount apportioned and applied. 12. Date of service of statutory notice of accident on employer and whether given before deceased voluntarily left the employment in which he was injured (a copy of the notice to be annexed). 13. If notice not served, reason for omission to serve same. 14. Date of claim for compensation. 15. Name of ship of which applicant was master, seaman or apprentice at date of accident, and port or registry. (See regulation 41). (If application is made by an employer insert here statement required by section 28(2)). Questions for the determination of the Court- (a) whether the deceased was a workman within the meaning of the Law; (b) whether the accident arose out of and in the course of the deceased’s employment; whether the amount of compensation claimed is due, or any part of the amount; (d) whether the respondent (or the applicant as the case may be) is liable to pay such compensation as is due; (e) whether the applicant(s) is a/are dependent(s) of the deceased; (f) how the compensation, when deposited, should be distributed; and (g) etc. (as required). To of I do hereby require you to lodge with me, the undersigned Clerk of the Court, within seven days after service hereof a written answer containing a concise statement of the extent and grounds of opposition, if any, to this application. And further take notice that the hearing of this application is fixed for the day of , 19 , at the abovenamed Court and that if you fail to lodge such answer or to appear at that time and place, an order may be made against you in default. Form 3 Regulation 4 Notice Whereas an application for compensation has been made by applicant, against and the said has claimed that you are liable under section of the Workmen’s Compensation Law (1996 Revision), to indemnify him against any compensation which he may be liable to pay in respect of the aforesaid application, you are hereby informed, that you may appear at o’clock on the day of , 19 , at the Grand Court holden at and contest the claim for compensation made by the said applicant or the claim for indemnity made by the respondent or both. In default of your appearance you will be deemed to admit the validity of any order made against the respondent and be liable to indemnify the respondent for any compensation recovered from him. I hereby require you to file with me the undersigned Clerk of the Court a written statement dealing with the claim against you in the above application within seven days after the service thereof on you. And further take notice that if you fail to forward the statement in writing an order may be made against you in default. To of Form 4 Regulation 8 Memorandum of Agreement (In case of a non-fatal injury to workman by accident) In the matter of the Workmen’s Compensation Law (1996 Revision) and In the matter of an agreement between of applicant, and of respondent, Be it remembered, that on the day of , 19 , personal injury was caused at to the abovenamed, a workman under no legal disability, (or a minor of the age of years) by accident arising out of and in the course of his employment. (Insert here the like particulars as in Form 1). And that on the day of , 19 , the following agreement was come to by and between the said and the said that is to say- (here set out the terms of the agreement). (If a medical referee has been appointed to report, add-) A copy of the report of , a medical referee appointed to report in the abovementioned matter is hereunto annexed. You are hereby requested to record this memorandum under section 17(4) of the above-mentioned Law. Dated Signature of employer Signature of workman (Note: An application to record an agreement can be presented under the signature of one party only, provided that the other party has agreed to the terms. Both signatures should be appended, whenever possible). Form 5 Regulation 8 Memorandum of Agreement (Where death resulted from the injury to workman) Article I. To the Clerk of the Court In the matter of the Workmen’s Compensation Law (1996 Revision) In the matter of an agreement between of and of Be it remembered, that on the day of , 19 , personal injury was caused at to late of deceased by accident arising out of and in the course of his employment, and that on the day of , 19 , the said died as the result of such injury. (Insert here the like particulars as in Form 2) And that on the day of , 19 , the following agreement was come to by and between the dependants of the said within the meaning of the above-mentioned Law and the said that is to say- (here set out terms of agreement). (If a medical referee had been appointed to report, add-) A copy of the report of a medical referee appointed to report in the abovementioned matter is hereunto annexed. You are hereby requested to record this memorandum under section 17(4) of the abovementioned Law. Dated Signature of employer Signature of above named dependants of deceased workman (Note: An application to record an agreement can be presented under the signature of one party only, provided that the other party has agreed to the terms. Both signatures should be appended, whenever possible). Form 6 Regulation 9 Notice of Memorandum Having Been Received Take notice that a memorandum, a copy of which is hereto annexed has been sent to me for registration. Such memorandum appears to affect you. I have therefore to request you to inform me within seven days from this date whether you admit or dispute the genuineness of the memorandum, or whether you object to the recording thereof, and if so on what grounds. If you do not inform me in due course that you dispute the genuineness of the memorandum or object to its being recorded, it may be recorded without further enquiry, and will be enforceable accordingly. If you dispute its genuineness, or object to the recording thereof, it will not be recorded except by order of the Court. To (insert names of all parties interested) Form 7 Regulation 10 Notice Disputing Genuineness of Memorandum Take notice that (state name of party disputing), a party (or parties) interested, disputes (or dispute) the genuineness of the memorandum sent to you for registration in the abovementioned matter on the following grounds- Here state grounds, as e.g.- (a) that no such agreement has in fact been entered into; (b) that the terms of the agreement are not correctly stated in the memorandum (setting out what is claimed to be the correct terms); that the agreement is no longer subsisting or enforceable; or (d) that the agreement is not enforceable by reason of its having been entered into under a mutual mistake (or having been obtained by fraud, undue influence or improper means). Form 8 Regulation 11 Notice that Genuineness of Memorandum is Disputed, or of Objection by Employer to Memorandum being Recorded Take notice that of a party (or parties) interested in the memorandum left with (or sent to) me for registration in the abovementioned matter, has (or have) filed with me a notice, a copy of which is sent herewith, that he disputes (or they dispute) the genuineness of the said memorandum on the grounds stated in the said notice. or Take notice that of (the employer) has/have filed with me an affidavit, a copy of which is sent herewith. that he objects or they object to the memorandum left with/sent to me for registration in the abovementioned matter being recorded on the grounds stated in the said affidavit. The memorandum will therefore not be recorded, except by order of the Court. To (all parties interested) Form 9 Regulation 13 Application for Cancellation of Agreement Application is hereby made to the Court by for an order cancelling an agreement dated the day of , 19 , between an employer and a workman determining: (Here set out the matter determined by the agreement in terms of section 17(1), and (2) of the Law) on the ground that (Here set out the grounds for cancellation in terms of section 17(2) of the Law). Form 10 Regulations 14 and 16 Application for Review or Redemption of Half-monthly Payment Application is hereby made for review (termination, diminution, increase or redemption as the case may be) of the half-monthly payment payable to the said in respect of personal injury caused to him by accident arising out of and in the course of his employment, on the day of , 19 , at . Particulars are hereto appended. Name and address of injured workman. Name and place of business of employer by whom compensation is payable. Date and nature of accident. Amount of half-monthly payment, and the date from which it commenced. Relief sought by applicant, whether termination, diminution, increase or redemption. Grounds of application. Form 11 Regulation 17 Application for Order for Payment to Dependent or Other Person of Half-monthly Payment Payable to Persons under Disability Take notice that I (name and address of applicant) intend to apply to the Court on the day of , 19 , for an order that the half-monthly payment payable in the dependent or to any other person best fitted to provide for the welfare of the said (name of workman under disability) and for consequential directions. and (names of all parties interested). Form 12 Regulation 18 Article II. Application for Variation of Order (Heading as in application) Take notice that I, (name and address of applicant) intend to apply to the Court on the day of , 19 , for an order that the order of the Court made in the above mentioned matter on the day of ,19 , as to the distribution of the sum paid as compensation among the dependants of deceased (or as to the manner in which the sum payable to a dependent of deceased, should be applied or otherwise dealt with) may be varied by directing (here state variation sought by applicant) and for consequential directions. And further take notice that the circumstances in which the application is made are (state and (names of all parties interested). Form 13 Regulation 20 Deposit of Compensation for Fatal Accident Compensation amounting to $ is hereby presented for deposit in respect of injuries in the death of residing at which occurred on the day of , 19 , at . His monthly wages are estimated at $ . He was over/under twenty-one years at the time of his death. The said workman had, prior to the date of his death, received the following payments, namely amounting in all to $ . This deposit is made pursuant to- (Here state the reason for making the deposit-see regulation 19.) (To be added if desired) I desire to be made a party to the proceedings for the distribution of the aforesaid (State names and addresses of dependants so far as are known) Form 14 Regulation 20 Statement of Disbursement Depositor Amount deposited $ Date _________________________________________________________________ Funeral expenses paid $ _________________________________________________________________ Compensation paid to the following dependants- Name Relationship ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------- Total $ -------------------------------------------------------------------------------------------------- Form 15 Regulation 23 Deposit of Compensation for Non-fatal Accidents Compensation amounting to $ is hereby presented for deposit in respect of permanent/temporary injuries sustained by residing at which occurred on the day of , 19 , at . This deposit is made pursuant to (here state the reason for making the deposit-see regulation 19). Dated Form 16 Article III. ORDER In case of Application for Half-monthly payment of Compensation That the respondent C. D. do pay to the applicant A. B. the half-monthly sum of $ as compensation for personal injuries caused to the said A. B. on the day of , 19 , by injury arising out of and in the course of his employment as a workman employed by the said respondent, such half-monthly payment to commence as from the day of , 19 and to continue during the total or partial incapacity of the said A. B. for work, or until the same shall be ended, diminished, increased or redeemed in accordance with the Workmen’s Compensation Law (1996 Revision). And that the said C. D. do forthwith pay to the said A. B the sum of $..., being the amount of such half-monthly payments calculated from the day of until the day of , 19 and do thereafter pay the said sum of $ to the said A. B. on the and days of each month. And that the said C. D. do pay to the applicant his costs of and incidental to this application fixed at the sum of $ (or to be taxed in accordance with the proper scale). Form 17 ORDER In Case of Application by Dependants That the respondent C. D. do pay the sum of $ to the dependants of A. B. late of deceased as compensation for the injury resulting to such dependants from the death of the said A. B. which took place on the day of , 19 , from the injury caused to the said A. B. on the day of , 19 , by accident arising out of and in the course of his employment as a workman employed by the said respondent. And it is declared that the persons hereinafter named are entitled to share in such compensation as dependants of the said A. B., that is to say J. B. widow of the said A. B. and (name the other persons). (Add if so found) And it is declared that G. H. the of the said A. B. is not entitled to share in such compensation as a dependent of the said A. B. And it is further ordered- That the said sum of $ be appointed between the said J. B. and in the proportions following- That the sum of $ to and for the benefit of the said J. B. and the sum of $ to and for the benefit of the said . That the said C. D. do pay the said sum of $ within fourteen days from the date of this Order. That the said J. B. and the said or any other of them be at liberty to apply to the Court from time to time for any further or other order as to the application of any of the said sums which may be ordered to be invested and the accruing interest thereof. That the said C. D. do pay to the applicants their costs of and incidental to this application fixed at the sum of $ (or be taxed in accordance with the proper scale). Form 18 ORDER In Case of Application by Persons to Whom Expenses of Funeral are Due That the respondent C. D. do pay the sum of $ for or towards the expenses of the funeral of A. B. late of deceased, who died on the day of , 19 , from injury caused on the day of 19 , by accident arising out of and in the course of the employment of the said A. B. as a workman employed by the said C. D. And it is declared that the persons hereinafter named are entitled to share in such compensation, that is to say- The applicant E. F. in respect of charges amounting to $ due to (or payable by) him in respect of charges amounting to $ for the funeral of the said A. B. (Note: The above form will serve as a guide for framing orders in other cases). Publication in revised form authorised by the Governor in Council this 16th day of June , 1998. Carmena H. Parsons Clerk of Executive Council