Australian Government Claim For Workers' Compensation Page 3
ADVERTISEMENT
1
2
3
4
5
6
7
8CLAIM FOR WORKERS’
COMPENSATION
Seafarers Rehabilitation and Compensation Act 1992
/
/
(Employer use only)
Date received
Employee details
1
Your full name
8
Do you need another person to act on your behalf
for this claim?
Mr
Mrs
Ms
Other
For example: a partner, support person or solicitor.
Family name
No
Yes
Please give details
Their name
Given name(s)
Their daytime telephone number
2
Do you have, or have you ever had, any other
name(s)?
Postal address
For example: maiden name or previous married name.
No
Yes
Please give details
What name(s)?
State
Postcode
Relationship
/
/
3
Date of birth
4
Gender
Male
Female
9
Do you have a preferred language other than
English?
5
Permanent home address
No
Yes
What language?
(please give street address and not a PO Box)
Do you need an interpreter?
No
Yes
Call the Translating and
State
Postcode
Interpreting Service on 13 14 50 if you require
assistance completing this form
6
Postal address
(if the same as home address write 'as above')
10 Name of employer at time of injury
State
Postcode
11 Payroll number or PIN (if known)
7
Contact details
(
)
Home
(
)
12 Name of home port
Work
Mobile
13 Occupation at the time of the injury or illness
Email
(rank/rating)
1
SEA01.1 May 2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal