1 general conditions of employment - Department of Education and ...

4 LEAVEAPPENDIX BTHE AUTHORITYAUTHORITYTo ................................................................. (Insurer).................................................................In the event of my recovering any damages or compensation (either in a contested action, or by way ofsettlement of any claim) in respect of an injury sustained by me on the ............ day of……............................., 20......., involving myself and ............................................…... I hereby authoriseand direct you to pay to the Department of Education and Training the amount equivalent to the paid sickleave granted to me by the said Department in respect of the abovementioned injury or illness, out of anymonies that are or may subsequently become payable by you either as a verdict in or as settlement of theaction or claim.And I hereby declare that:1) A certificate signed by or on behalf of the Director-General of the said Department in respect ofpaid leave granted to me shall, for the purpose of any payment under this authority, be conclusiveevidence of such paid leave granted;2) I, or a solicitor or agent, acting on my behalf, will provide all information to the Department inrelation to the claim under the Workers' Compensation Act 1987, the injury or illness which gaverise to the claim, and the compensation payable by the Insurer;3) I will immediately notify and furnish all particulars to the said Department if I, or a solicitor oragent, acting on my behalf, makes a claim being lodged under the Workers' Compensation Act1987 for the same injury or illness;4) In the event of the claim specified in (3) above being made, I will immediately sign theundertaking, in respect of repayment of sick leave granted, required for claim for compensationand damages made other than under the Workers' Compensation Act 1987;5) This authority is irrevocable.Dated this ............................ day of ..............................., 20.............................................................................Applicant.................................................................Witness................................................................AddressHandbook for non teaching staff in schools 2007 Page 4 - 61