Form Wor0028a - Workers' Compensation Employer'S Report Form

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Workers‘ Compensation
Employer’s Report Form
It is essential that this form be completed to enable the worker’s entitlement to compensation
to be promptly determined.
Payments should not be commenced until authorised by us.
If claim for medical expenses and no time has been lost, complete all questions except
questions 14. Please use “BLOCK” capitals.
Risk Codes (if applicable)
Policy no.
:
:
:
:
:
:
:
:
:
1. Employer details
Full name of employer
Trading name of employer
Type of Business
Address
Postcode
Facsimile no.
Contact name
Business telephone no.
(
)
(
)
Email address
2. Injured worker
Surname
Given name(s)
Address
Postcode
Private telephone no.
Worker’s occupation
(
)
Age
Date of birth
Relationship (if any) to employer
No
Yes
Married:
/
/
3. Accident
Date of accident
Time
Day of week
/
/
am/pm
How long had the employee worked, on the date of the accident, before the injury?
hrs
mins
Date work ceased
Time
/
/
am/pm
/
/
am/pm
Date first Medical Certificate received by employer
at
Date claim form received from worker
at
/
/
am/pm
No
Yes
Was the worker affected by alcohol or drugs?

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