Witness Statement Form (Page 2 of 2) in pdf

Witness Statement Form Page 2

Details of disability

Describe the resulting disability. (State fully the type and position of the disability, for example ‘cut on upper/lower arm, grazed

right ankle, burnt back of left hand’).

Declaration

I acknowledge that Section 308 of the Workers Compensation and Injury Management Act 1981 provides that any person

who by a false statement or other means, aids or abets a person in a fraudulent attempt to obtain any bene t under the Act

commits an offence. I certify that this is a true statement.

I agree that, by submitting this form, the personal information I provide to CGU Workers Compensation in this form or otherwise

may be collected, held, used and disclosed in the manner set out in the CGU Privacy Policy found at ,

including for processing this claim.

Name of witness

Signature

Date

In the presence of

Signature

Date

Insurance Australia Limited trading as CGU Workers Compensation ABN 11 000 016 722.

46 Colin Street West Perth WA 6005 GPO Box 929 Perth WA 6843

Tel. 1300 307 952 Fax (08) 9264 2286

WOR0138 REV7 11/13

Witness Statement Form Page 2