Form Wor0028a - Workers' Compensation Employer'S Report Form Page 4
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42. Which of the following covers the status of the worker’s employment?
Full Time
No. of hours per week
Part Time
No. of hours per week
Casual
The number of weeks he/she has worked for you over the past year
Seasonal
Length of season in weeks over 12 month period
14. Worker’s earnings
To enable us to calculate this worker’s weekly compensation rate please provide details of their past earnings.
For award workers we require 13 weeks past earnings before the date of incapacity. If employed less than
13 weeks, we only require the past earnings over the period of employment with you. You will also need to
complete the details of the Award or Agreement requested below*.
For non-award workers we require 12 months past earnings before the date of injury including all bonuses
and allowances. If employed for less than 12 months, we only require the past earnings over their period of
employment including the number of weeks employed by you.
Award
Non Award
Period
Gross Amount
Period
Gross Amount
Week 1
$
Month 1
$
Week 2
$
Month 2
$
Week 3
$
Month 3
$
Week 4
$
Month 4
$
Week 5
$
Month 5
$
Week 6
$
Month 6
$
Week 7
$
Month 7
$
Week 8
$
Month 8
$
Week 9
$
Month 9
$
Week 10
$
Month 10
$
Week 11
$
Month 11
$
Week 12
$
Month 12
$
Week 13
$
Award or Enterprise Agreement
Name of Award or Enterprise Agreement
Base Award Rate and Hours
Over award amount paid on a regular basis (excluding allowances)
Shift Allowance
Bonus
Casual Allowance
Other Allowances (otherwise not specified)
Please sign this form if you agree with the circumstances of the accident
Date
Official position
Signature of the employer
/
/
NOTE: This form is to be signed by a person (other than the injured worker) authorised by the employer
Insurance Australia Limited ABN 11 000 016 722 trading as CGU Workers Compensation
46 Colin Street West Perth WA 6005 GPO Box M929 Perth WA 6843
Tel. (08) 9264 2222 Fax (08) 9264 2292 or (08) 9264 2286
WOR0028A
REV5 7/09
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