Workers Compensation Claim Form 2b (Reg 6aa) Page 4
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Employer details
To be completed by employer after receipt from the worker and forwarded to the insurer within 3 full working days
Insurance Co.
Name of policy holder
Address
Policy No.
Suburb/town
Postcode
Full name of employer:
Trading as:
e.g. E.J. Imports
WorkCover No.
Browns Pharmacy;
Address of worker’s usual
Workplace or base
WC …………………...
Postcode
Major activity of workplace:
Claim No:
e.g. sheep or grain farming;
Insurer/Self-insurer
Aluminium window screen
to complete
manufacturing
Office use only
ANSIC CODE
Injured worker details
?
Surname
Mr/Mrs/Miss/Ms
Date of birth
Age
Sex
/
/
Male/Female
If you have difficulty understanding
Other names
English, what is your preferred
language?
Address
……………………………………………..
At the time of the occurrence
Postcode
were you working as a:
- direct employee?
1
Phone No.
- working director?
2
- contractor?
3
- employee of contractor?
4
Occupation e.g. first class welder, accounts clerk
- sub-contractor?
5
- other?
6
ASCO
Main tasks or duties performed? e.g. welding of high pressure steam
pipes; recording and paying accounts
full time
F part time
P
…………………………………………..……..…
permanent
P temporary
T casual
C
Occurrence details
?
Day of
Date
/
/
Time
:
am/pm
Occurrence
At what address did the occurrence occur?
When did you have to stop working?
Date
/
/
Time
:
am/pm
Were you- working, and:
-on a work break and:
,
- at your usual workplace?
A
-
- at your usual workplace
E
- at a diiferent workplace?
B
-
-not at your usual workplace?
F
- in a road traffic accident
C
- doing something else? (please describe below)
O
-
travelling between home and work?
D
………………..………………..……..
-
What actually happened and what caused the occurrence? Include:
Mechanism
(i) what action was involved, e.g. – fall, caught between, struck by moving object
______________________________________________________________________________________________
Agency
______________________________________________________________________________________________
(Ii) what object/machine/substance was involved, e.g. petrol fumes, wooden door frame
______________________________________________________________________________________________
Nature
Describe:
i)
the most serious injury or disease caused
Bodily
by the occurrence, e.g. fracture, burn, cut, abrasion
Location
______________________________________________________________________________________________
ii) bodily location of the injury or disease, e.g. upper arm, ankle, eye
Insurer/Self-insurer’s Date Stamp
Insurer/Self-insurer to complete
Estimated time off work –
• 10-20 work days (inclusive)
• less than 1 day
• more than 20 work days
• 1-4 work days (inclusive)
• fatality
• 5-9 work days (inclusive)
• Has employer faxed medical practitioner
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