Referral to Tribunal (S81A). doc

WORKERS REHABILITATION AND COMPENSATION ACT 1988
REFERRAL TO TRIBUNAL (S.81A)
To the Registrar, Workers Rehabilitation and Compensation Tribunal
Employer: The State of Tasmania (Department of )
Worker:
Fund Administration Agent

(as Agent for the State of Tasmania): Jardine Lloyd Thompson Pty Ltd

1. We, the State of Tasmania (Department of ), being the employer of who has made a claim for compensation under the Act in relation to an injury, dispute any liability to pay compensation by way of weekly payments and/or cost of benefits under Division 2 Part VI in respect of the injury.

2. We hereby refer the matter to the Tribunal under Section 81A.

3. We have notified the worker in writing that we dispute liability to pay compensation and have informed the worker of our reasons for disputing liability.

4. Weekly payments are/are not being made to the worker.

5. We enclose the required documents with this referral.

Our reasons for disputing liability to pay compensation are as follows [specify reason(s), for example]:

1. 
   there is insufficient evidence that the worker is incapacitated for work as certified; and/or
   
2. 
   there is insufficient evidence to substantiate the claim that the injury/disease [specify which] arose out of or in the course of the worker’s employment, or [if it is a disease] that the employment contributed to it to a substantial degree; and/or
   
3. 
   if the relationship between the injury/disease and employment required by Section 25(1) is established, then the injury arose from reasonable action taken in a reasonable manner by the employer; and/or
   
4. 
   the expenses incurred are not reasonable expenses; and/or
   
5. 
   the expenses have not been necessarily incurred; and/or
   
6. 
   the expenses have not been incurred as a result of the said injury; and/or
   
7. 
   the certificate submitted is materially different to certificates previously delivered in that ; and/or
   
8. 
   notice of the injury/disease was not given as soon as practicable as required by the Workers Rehabilitation and Compensation Act 1988; and/or
   
9. 
   the claim for compensation was not made with six (6) months of the date of injury.
   

Investigations will be completed by approximately .
The following documents are attached to this referral:
‮ Claim form and medical certificate

‮ Letter to worker under Section 81A(1)

Jardine Lloyd Thompson Pty Ltd

as Agent for and on behalf of the State of Tasmania
Dated
[NOTE: Three (3) copies of this referral and all its attachments must be lodged with the Tribunal]