Claim Form - Return To Work - Government Of South Australia Page 3
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4Section 4 - Capacity for work and treatment
Section 6 - Income support
Please complete section 6 if claiming for loss of wages.
4A - Treating doctor’s information
Name:
__________________________________________________
6A - Worker’s hours
Practice name:
____________________________________________
Is the worker:
Practice phone:
___________________________________________
permanent or
casual
Practice address:
__________________________________________
Normal hours per week?
_________
hours
Suburb / town: _____________________Postcode:
______________
Regular hours each day of the week:
Hospital
:
__________________________
(if the worker was or is hospitalised)
Mon
Tue
Wed
Thu
Fri
Sat
Sun
4B - Work Capacity Certificate details
OR
The worker’s Work Capacity Certificate covers the period from:
tick if not regular hours (e.g. shiftwork)
to
Is the worker:
full time or
part time
Section 5 - Employment details
If the worker works part time, what would their hours be
if they worked full time?
_________
per week (if known)
5A - Employer’s name and address
Full company or business name:
_____________________________
6B - Worker’s income details
Trading name:
____________________________________________
What was the worker’s gross weekly wage at
Postal address:
___________________________________________
the time of the injury? $
Suburb / town: _____________________Postcode:
______________
Does the worker normally work overtime?
Phone:
__________________________________________________
Yes
No
Email:___________________________________________________
If yes, what is the average amount earned per week? $
(Note: Providing an email address will ensure prompt receipt of important notices)
What are the average hours of overtime per week?
ReturnToWorkSA employer number:
___________________________
Does the worker receive non-cash benefits?
Yes
No
ReturnToWorkSA location number:
____________________________
If ‘Yes’ what is the benefit? (e.g. car, phone, computer)
Date worker started employment:
________________________________________________________
Address of worker’s usual workplace
:
(if different from above)
(Note: 12 months of wages information may be requested in order to determine
Average Weekly Earnings.)
___________________________________________________________
6C - Other employment details
Suburb / town: _____________________Postcode:
______________
Does the worker have any other current employment?
5B - Employer contact person for this claim
Yes
No
(e.g. Manager or Return to Work Coordinator)
Name:
__________________________________________________
Section 7 - EFT details
Phone:
__________________________________________________
Position title:
_____________________________________________
Payments and reimbursements are paid by EFT.
Email:___________________________________________________
7A - Worker’s Electronic Funds Transfer (EFT) details
5C - Employment type
Bank name:
____________________________
/
Is the worker any of the following? (if not leave blank)
BSB number:
an apprentice
a trainee
a working director
Account number:
_________________________________________
If the worker is not an employee what is the relationship?
Account name:
___________________________________________
(e.g, non-working director, sole contractor, partner):
7B - Employer’s EFT details
________________________________________________________
Bank name:
___________________________
5D - Worker’s occupation and main tasks
/
BSB number:
Occupation:
______________________________________________
Account number:
_________________________________________
Main tasks:
_______________________________________________
Account name:
___________________________________________
________________________________________________________
________________________________________________________
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