1964_EMPLOYEES__COMPENSATION_(RULES_OF_COURT)_RULES — Page 13

1

1983 Ed.]

Employees' Compensation (Rules of Court) Rules

[CAP. 282

B 13

[Subsidiary]

(b) *At all material times the 1st respondent was a sub-contractor within the meaning of the Ordinance to a principal contractor within the meaning of the Ordinance namely the 2nd respondent.

2.

An application under the Ordinance is hereby made by acting on behalf of the dependants of the deceased employee against the respon- dent(s) for compensation pursuant to the Ordinance.

3.

Particulars are as follows-

PARTICULARS

(1) Date of birth or age of the deceased employee at the date of the accident

(2) Nature of employment of the deceased at the time of the accident

(3) Date and place of accident, nature of work on which the deceased was then

engaged, and nature of accident and cause of injury

(4) Nature of injury to the deceased and date of death

(5) Monthly earnings of the deceased from employment with the respondent-

(a) for the month immediately preceding the accident

(b) on average during the 12 months (or any lesser period of employment

with the employer) prior to the accident

(6) Particulars as to dependants of the deceased by whom or on whose behalf

the application is made-

Name

Description] Address Occupation

Relationship to the deceased

Wholly!

Partially

Age

Dependent

(7) Amount claimed as compensation

(8) Date of giving notice of accident to respondent(s)

(9) If notice not given, reason for omission to give such notice

The name and address of the applicant or his solicitor are-

are

Of the applicant

Of his solicitor

The name and address of the respondent(s) to be served with this application

Dated this

day of

19

* Delete as required.

Applicant/Solicitor for the Applicant