| Employer * |
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Employee * |
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| D.O.I. * |
[DD/MM/YYYY] |
D.O.B * |
[DD/MM/YYYY] |
| Injury details* |
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| How did injury occur |
| |
| Where did injury occur |
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| Who reported injury |
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| Injured Workers Details |
| Address |
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| Suburb |
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State |
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| Postcode |
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Phone |
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| Other Details |
| Do you have any concerns with validity of claim |
Yes No |
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| Explanation (if yes) |
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| Has the worker returned to pre-injury duties Yes No |
Date resumed |
[DD/MM/YYYY] |
| Has the worker returned to light duties Yes No |
Nil returned to work |
Yes No |
| Insurer Details |
| State of Workers Compensation Policy * |
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| If NSW, Is worker likely to have 7 days or more off work, if so you are required to notify workcover on 02 |
| Workers Compensation Insurer * |
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| Policy Number |
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| Name of person reporting Injury |
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| Name of return to Work Leader |
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| Email Address |
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| Phone Number |
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| Business Phone Number |
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Fax |
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| Address |
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| Suburb |
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Town |
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| State |
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Pin Code |
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| Additional Information |
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| Do you have a medical Certificate Yes No |
Issue Date |
[DD/MM/YYYY] |
| Name of treating Doctor |
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| Address |
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| Suburb |
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Town |
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| State |
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Pincode |
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| Phone Number |
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| Helpful Comments |
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