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Form #1705Special Power of Attorney for Injury on Duty claim
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this form can be used by a claimant in an injury on duty matter to appoint a third party to investigate the injury and/or IOD claim with the relevant Department of Labour, Employer or Workers Compensation Commission.
it can also be used by an attorney or third party acting on behalf of a claimant to pursue/query an IOD claim to get the necessary power of attorney to act on that persons behalf.
"cant be used outside of South Africa"
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SPECIAL
POWER OF ATTORNEY
I, the
undersigned --------------------------------------------------------------------------
Do hereby
nominate, constitute and appoint
(full
name) of (name of Company)
With power of
substitution to be my lawful Attorney and Agent in my name, place and stead
and under whose specific instruction those acting under his specific employ,
instruction or association will be able
(a) To investigate the circumstances
relating to an injury on duty matter in which I/ my spouse was injured/killed
and which occurred on the ------------------------------------------------ at
----------------------------------------------------------------------------
(b) To obtain from the relevant
Department of Labour, Employer and the Workers Compensation Commission office,
witnesses and relevant hospitals and Doctors concerned all facts, medical
reports, accounts, documents and details relating to the injuries sustained.
(c) To sign the necessary claim form
on my behalf and therein to assist with the submission of all documents and
information relating to compensation claimable for damages (in my said
attorneys discretion)
(d) To negotiate a settlement with
the Workers Compensation Commission offices concerned and to agree with them on
figures of settlement/award and to advise me thereof.
(e) To sign and release or discharge
for the amount of the settlement in order to receive and recover the said
amount.
(f) To discuss all matters necessary
for the purpose of obtaining the necessary reports, etc above mentioned for
which disbursements I shall be liable in addition to all my Attorneys fees,
whether by way of attorney and client service fee or otherwise.
(g) To do all that is necessary to
finalise the said claim for compensation and in so doing, I confirm that this
power is irrevocable.
(h) To sign a Power of Attorney to
Sue and Defend
And generally
for effecting the purpose of the aforesaid to do or cause to be done whatsoever
shall requisite, as fully and effectually, for all intents and purposes, as he
might or could do if personally present and acting herein-hereby ratifying,
allowing and confirming and promising and agreeing to ratify, allow and confirm
all and whatsoever my said Attorney and Agent shall lawfully do, or cause to be
done by virtue of these present.
SIGNED
AT THIS DAY
OF 2014
In
the presence of the undersigned witnesses: -------------------------------
DEPONENT
As
witnesses:
1. ----------------------------------------
2. ------------------------------------------------
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not be construed as legal advice. You are strongly encouraged to consult competent
legal council before engaging in any action based upon content contained on this
site.
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or any other commercial use is prohibited. This includes reposting forms from this
site to another site offering free legal or other document forms for download.
Please note that the donator may have included different usage terms regarding this
form, and you agree to abide by these terms. It is highly recommended that you have
a licensed attorney review any legal documents for which you are searching in order
to make sure that your needs are being properly and completely satisfied.
Your use of this site constitutes your acceptance of our terms of use and your agreement
to hold this site, its officers, employees and any contributors to this site harmless
for any damage you might incur from your use of any submissions contained on this
site. If you do not agree to the above terms, please do not proceed.
These forms are provided to assist business owners and others in understanding important
points to consider in different transactions. They are offered with the understanding
that no legal advice, accounting, or other professional service is being offered
by these documents or on this website. Laws vary in the different states. Agreements
acceptable in one state may not be enforced the same way under the laws of another
state. Also, agreements should relate specifically to the particular facts of each
situation. Therefore, it is important to consult legal counsel whenever utilizing
these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com
is not engaged in recommending or referring members on the site or making claims
about the competence, character or qualifications of its participating members.
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Keywords: Special Power of Attorney, IOD Special power of Attorney, Injury on Duty, IOD form
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