1964_EMPLOYEES__COMPENSATION_(RULES_OF_COURT)_RULES — Page 21

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1983 Ed.]

Employees' Compensation (Rules of Court) Rules

[CAP. 282

B 21

[Subsidiary]

Particulars are hereto appended (or annexed)—

PARTICULARS

(1) Name and address of injured employee

(2) Name and place of business of employer by whom compensation is

payable

(3) Date and nature of accident, and injury

(4) Date of order or agreement fixing monthly payment, amount of such

payment, and date from which it commenced

(5) Relief sought by applicant, (whether termination, suspension, diminution,

or increase)

(6) Grounds on which (termination, suspension, diminution or increase) is

claimed-

are-

The names and addresses of the applicant and his Counsel or Solicitor

Of the applicant:

are

Of his Counsel

or Solicitor:

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

Dated this

day of

... 19......

Applicant (or his Counsel or Solicitor)

The

Case No.

FORM 9

EMPLOYEES' COMPENSATION (RULES OF COURT) Rules Order on Revision of Order/Agreement for Periodical Payments

In the matter of an Application between-

Court of

[rule 28.]

applicant,

and

...., respondent.