Workers Compensation Claim Form 2b (Reg 6aa) (Page 3 of 6) in pdf

WORKERS’ COMPENSATION CLAIM FORM 2B (REG 6AA)

SECTION 84I(1)(b) OF THE WORKERS’ COMPENSATION AND REHABILITATION ACT 1981

INSTRUCTIONS FOR THE INJURED WORKER

YOU MUST COMPLETE THE BLUE SECTION OF THIS FORM IF YOU WISH TO CLAIM WORKERS’

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COMPENSATION

PLEASE USE A BALLPOINT PEN

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ENSURE THE ORIGINAL COPY AND DUPLICATE ARE COMPLETE AND LEGIBLE.

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ONCE COMPLETED GIVE THIS FORM AND YOUR FIRST MEDICAL CERTIFICATE TO YOUR EMPLOYER AS

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SOON AS YOU CAN.

TO THE EMPLOYER

Ensure the worker completes this claim form. If the worker is unable to complete this form please arrange for

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the form to be completed on their behalf.

Make sure you complete the employer details section (red box).

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Give the information tear off section at the front of the claim form to the injured worker.

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Forward this form, medical certificate(s), medical accounts (if any), and the employer’s report within 3 full

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working days of receipt from the worker to your insurance company [Section 57A(2)].

For a motor vehicle accident and journey report form (available from your insurance company) should also be

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completed and returned.

Review the First Medical Certificate’s “Doctor/Employer Contact” section. If the doctor has indicated the

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worker will be off work for 3 days or more, or is unable to return to normal duties, she/he will be expecting

contact from you to discuss return to work options.

If the doctor has requested contact from you on the First Medical Certificate, complete the “Details to be

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Provided to Doctor” section of the claim form (page 7), and fax it to the doctor.

Forward subsequent medical certificates and accounts to your insurance company as soon as you receive them.

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You are required to keep an injured worker’s job open for 12 months from the day the worker became

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entitled to receive weekly payments of compensation. If the injured worker becomes partially or totally fit

for work within 12 months, from the day they became entitled to receive weekly payments of

compensation, you must provide them with their pre-injury job, if reasonable practicable, or another job

comparable to status and pay to their pre-injury position for which they are qualified and capable of performing.

Report accidents notifiable under the Occupational Health, Safety and Welfare Acts to WorkSafe Western

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Australia on 9327 8777.

PRIVACY AMENDMENT (PRIVATE SECTOR) ACT 2000

Your employer’s insurance company needs to collect, use and disclose personal information to assess, investigate and otherwise deal with

your claim. If you do not provide the information requested but this may affect the insurer’s ability to do those things.

1. By providing your personal information, you consent to the insurer –

(a)

collecting and using your personal information for the purposes of assessing, investigating and otherwise dealing with your current

or any subsequent claim; and

(b)

for these purposes, disclosing personal information (on a confidential basis) to and collecting personal information from –

(i)

your employer, the insurer’s related entities, its investigators, auditors, medical service providers or any other party providing

services to the insurer or any agent of these;

(ii)

other insurers, insurance intermediaries, government regulators or insurance reference bureaux; or

(iii)

lawyers and law enforcement agencies.

General Information on Workers’ Compensation and Rehabilitation can be obtained from WorkCover WA, 2

Bedbrook Place, Shenton Park WA 6008, Telephone: (08) 9388 5555, Country calls 1800 670 055, Facsimile

(08) 9388 5550, TTY (for the hearing impaired) (078) 9388 5537.

Workers Compensation Claim Form 2b (Reg 6aa) Page 3

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