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DCEC /
IN THE DISTRICT COURT OF THE
EMPLOYEES' COMPENSATION CASE NO. OF
____________
IN THE MATTER OF AN APPLICATION BETWEEN:-
Applicant
and
Respondent
_______________
______________________________
APPLICATION
_____________________________
1. (a) On , a personal injury arising out of and in the course of employment was caused by accident to the Applicant, an employee employed by the Respondent.
(b) At all material times the Respondent was an employer within the meaning of the laws of.
2. An application under the Ordinance is hereby made by the Applicant for the following relief or order:-
(a) Compensation under sections 9, 9(1A), 10 & 10A of the Ordinance;
(b) Interest; and
(c) Costs.
3. Particulars are as follows: –
PARTICULARS
(1) Date of birth or age of the Applicant at the date of the accident:-
The Applicant was born on the and was aged at the time of the accident.
(2) Nature of employment of the Applicant at the time of the accident:-
The Applicant was employed by the Respondent as a .
1. Date and place of accident, nature of work on which the Applicant was then engaged and nature of accident and cause of injury:-
On (“the Date of the Accident”). At around , the Applicant was working at (“the Place of the Accident”) and (“the Accident”).
1. Nature of injury:
As a result of the Accident, the Applicant sustained serious injuries to his .
1. Particulars of incapacity and/or of constant attention:
Immediately after the Accident, the Applicant suffered from and he was admitted to the Accident & Emergency Department of . He was then given a sick leave certificate and discharged.
(6) Monthly earnings of the Applicant from employment with the Respondent:
About per month
1. For the month immediately preceding the accident:
About per month (Subject to discovery)
1. On average during the 12 months (or any lesser period of employment within the employer) prior to the accident:
About per month
1. If temporary incapacity pursuant to section 10 of the Ordinance is alleged, monthly earnings (if any) which the Applicant is earning or is capable of earning (if known) during the period of temporary incapacity:
To be assessed
1. Amount claimed as compensation:
To be assessed.
1. Date of giving notice of accident to the Respondent(s) :
Oral notice has been given to the Respondent.
1. If notice not given, reason for omission to give such notice:
The Respondent was fully aware of the accident in any event.
The name and address of the Applicant: -
The name and address of the Respondent to be served with this Application are:-
Dated this day of
The Applicant in Person
STATEMENT OF TRUTH
I, , the Applicant, believe that the facts stated in this Application are true.
Dated this
The Applicant
Notice to Respondent
1. If the only remedy that the Applicant is seeking is the payment of a liquidated amount of money or the payment of an unliquidated amount of money, irrespective of whether there is any appeal under Section 18 of the Employees’ Compensation Ordinance (Cap. 282) or any application for cancellation of any injuries claim certificate under Section 16B of the Employees’ Compensation Ordinance (Cap.282), you may admit the Applicant’s claim in whole or in part by completing Form No. 16 or Form No. 16C (as the case may require) accompanying the Application.
2. A completed Form No. 16 or Form No. 16C must be filed with the Registry of the District Court and served on the Applicant or the Applicant’s solicitors within 14 days after service of the Application.
3. The Respondent’s Answer (Form 5 of the Schedule of the Employees’ Compensation (Rules of Court) Rules (Cap. 282, sub. leg. B)) must be verified by a Statement of Truth in accordance with Order 41A of the Rules of the District Court (Cap. 336, sub. leg. H).
Form 16C
Admission (unliquidated amount)
(Order 13A rules 6(2), 7(2) & 13(2))
DCEC /
IN THE DISTRICT COURT OF THE
EMPLOYEES' COMPENSATION CASE NO. OF
____________
IN THE MATTER OF AN APPLICATION BETWEEN:-
Applicant
and
Respondent
_______________
Explanatory Note
1. The only claim the applicant has made against you is for an unliquidated amount of money. You may admit the applicant’s claim in whole or in part by completing this form –
(a) within the period for service of your Answer if you have been served with a Application; or
(b) the period for filing of your affidavit evidence if you have been served with an Originating Summons; or
(c) within 14 days after service of the originating process in any other case.
2. If you have made an admission, you may only be allowed to amend or withdraw your admission if the Court considers it just to do so.
3. You may offer a specified amount to satisfy the claim. If the amount you offer is accepted by the applicant, the applicant may request the Court to enter judgment against you for that amount. Alternatively, the applicant may request the Court to enter judgment against you for an amount to be decided by the Court and costs.
4. You may also ask for time to pay. If the applicant does not accept your proposal for payment, the Court will decide how the payment should be made after considering –
(a) the information set out in this form;
(b) the reasons why the applicant does not accept your proposal for payment; and
(c) all other relevant matters.
5. The completed form should be filed in the Registry of the District Court.
How to fill in this form
• Tick the correct boxes and give as much information as you can. Then sign and date the form. If necessary provide details on a separate sheet, add the action number and attach it to this form.
- If you do not ask for time to pay, you need not complete items 2 to 9 and 11 and 12.
- If you are not an individual, you need not complete items 1 to 9 but you should complete items 10 to 12 and ensure that you comply with the requirement specified in item 13 and provide sufficient details about the assets and liabilities of your firm, company or corporation to support any offer of payment made.
• If you are an individual, you need not complete items 10 to 12 and need not comply with the requirement specified in item 13.
• You can get help to complete this form at the Registry of the District Court.
Part A Response to claim (tick one box only)
□ I admit liability for the whole claim but want the Court to decide the amount I should pay (if you tick this box, you need not complete Part B and items 2 to 9, 11 and 12 and need not comply with the requirement specified in item 13)
OR
□ I admit liability for the claim and offer to in satisfaction of the pay claim
Part B How are you going to pay the amount you have admitted? (tick one box only) □ I offer to pay on (date)
OR
□ I cannot pay the amount immediately because (state reason)
AND
I offer to pay by instalments of per(week)(month) starting (date)
- Personal details
Surname
Forename
□Mr □Mrs □Miss □Ms
Address
- Dependants (people you look after financially)
(give details)
- Employment
□ I am employed as a
My employer is
Jobs other than main job
(give details)
□ I am self employed as a
Annual turnover is
□ I am not in arrears with my mandatory provident fund contributions and income tax
□ I am in arrears and I owe
Give details of :
1. (a) contracts and other work in hand
(b) any sums due for work done
□ I have been unemployed years for months
□ I am a pensioner
- Bank account and savings (please list all)
Bank account In credit by Overdrawn by
- Residence
I live in my own flat my jointly owned flat public housing estate rented private flat others (please specify)
- Income
My usual take-home pay (including overtime, commission, bonuses etc)per month
My pension(s)
per month
Others living in my home give me
per month
Other income (give details below)
per month
per month
per month
Total income per month
- Other assets (please list and indicate their location)
- Expenses
(Do not include any payments made by other members of the household out of their own income) I have regular expenses as follows:
Mortgage (including second mortgage)per month
Rent per month
Rates and government rent per month
Management fees per month
Domestic helper’s salary per month
Gas per month
Electricity per month
Water charges per month
Telephone charges per month
Housekeeping, food, school meals per month
Travelling expenses per month
Children’s clothing per month
Tuition fees per month
Maintenance payments per month
Court orders
Others
per month
per month
per month
per month
Total expenses
per month
- Liabilities
(This section is for arrears only. Do not include regular expenses listed in item 8.)
Rent arrears $
Mortgage arrears $
Rates and government rent arrears $
Water charges arrears $
Fuel debts: Gas $
Electricity $
Others $
Maintenance arrears $
Loans and credit card debts (please list)
Others (give details below)
$
$
$
Total liabilities
$
- Firm, company or corporation
Name
Address
Tel. no.
- Assets of firm, company or corporation (please list)
Property, plant and equipment $
Inventories $
Goodwill and other intangible assets $
Loans and receivables $
Bank balances and cash $
Others $
Total$
- Liabilities of firm, company or corporation (please list)
Trade payables $
Tax payables $
Other payables $
Bank loans $
Other borrowings $
Others $
Total $
- Attach to this form a copy of the latest audited profit and loss account and balance sheet of the firm, company or corporation.14. Declaration I _____________________________ declare that the details I have given above and in the attached sheet(s) (if any) are true to the best of my knowledge
And I make this solemn declaration conscientiously believing the same to be true and by virtue of the
Oaths and Declaration Ordinance (Cap. 11)
Signed Position or office held
(If signing on behalf of a firm, company or corporation)
With company chop
(if applicable)
Declared at ________________ in on _____________ of 20 ________.
Before me,
[Signature and designation, i.e., Justice of the Peace/Notary Public/Commissioner for Oaths.]
Note – Under section 36 of the Crimes Ordinance (Cap. 200), a person who knowingly and wilfully makes a statement false in a material particular in a declaration or other document which he is authorised or required to make by an enactment is guilty of an offence.
– A respondent who is an individual must sign personally. A director of company must comply with Order 5A, rule 2(b) and 2(c) of the Rules of the District Court (Cap.336, sub. Leg. H) before he may sign on behalf of the company.
– If an applicant does not file a request for judgment within 14 days after this form is served on him, his claim is stayed until he files the request.
