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[接上页] ............................................................................................................................. (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- .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. The names and addresses of the applicant and his Counsel or Solicitor are- Of the applicant: .................................................................................................... ..................................................................................................... .....................................................................................................Of his Counsel ..................................................................................................... ..................................................................................................... .....................................................................................................or Solicitor: ..................................................................................................... ..................................................................................................... .....................................................................................................The name and address of the respondent to be served with this application are .................. ............................................................................................................................................. Dated this .................... day of .................. 19 ......... .................................................................... Applicant (or his Counsel or Solicitor) __________ FORM 9 [rule 28] EMPLOYEES' COMPENSATION (RULES OF COURT) RULES Order on Revision of Order/Agreement for Periodical Payments The ................................................................. Court of ....................................................... Case No. .............................................................................................................................. In the matter of an Application between- .............................................................................................................................., applicant, and.........................................................................................................................., respondent. Before ...................................................................................................................... on .................. day, the ...................... day of .......................... 19 ....... Upon revision of the order for periodical payments made ................................................. on the .................... day of ......................... 19 .......... (or the agreement arrived at between the said parties on the ....................... day of ............................... 19 ..........) and upon hearing the evidence given by ................................ and Mr. .............................. for the applicant and Mr. ............................ for the respondent. It is hereby ordered that the said order/agreement be varied in the following manner: ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. |