MAGISTRATES' COURT (MISCELLANEOUS CIVIL PROCEEDINGS) RULES 2010
Rule 6.04(1)(b)
CHAPTER II
FORM 6C
NOTICE OF REQUEST PURSUANT TO SECTION 45(1)(b) OF THE ACCIDENT
COMPENSATION ACT 1985* / SECTION 304 OF THE WORKPLACE INJURY REHABILITATION
AND COMPENSATION ACT 2013*
IN THE MAGISTRATES' COURT
OF VICTORIA AT
Court Number
BETWEEN
Plaintiff
Of: (address)
and
Defendant
Of: (address)
Date of Document:
Filed on Behalf of:
Australian Lawyer name:
Address
Code:
Telephone:
Reference:
In the matter of the Accident Compensation Act 1985* / Workplace Injury Rehabilitation and
Compensation Act 2013*
Take notice that (identify party)
will request the Magistrates’ Court at (venue)
on (date)
at (time)
to refer the following medical questions to a medical panel for an opinion—
(a)
(b)
(c)
Dated:
_______________________________________
[Signed]
* Delete if not applicable
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