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Form #1705

Special 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. ------------------------------------------------

Contributed by
Omega Legal Services
 
Total Forms Contributed 2
 

See All Omega Legal Services's Forms
 

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Terms Of Use

Submissions to this site, including any legal or business forms, posts, responses to questions or other communications by contributors are not intended as and should 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.

These downloadable forms are only for personal use. Retransmission, redistribution, 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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