Workers Compensation Claim Form 2b (Reg 6aa) (Page 5 of 6) in pdf

Occurrence Report

Where did the occurrence occur? e.g. store room, machinery shop

What were you doing at the time of the occurrence?

What were the normal working hours for

Starting

Finishing

am/pm

that day?

Time

When did you first report the occurrence?

Date

Time

am/pm

To whom did you report the occurrence?

Name/Title

If the occurrence was not reported

immediately, state the reason?

Name and address of witness(es) to the

occurrence:

Medical Attention/history – this event

1. When did you first seek medical attention?

Date

Time

am/pm

2. If not immediately, state reason:

3. Was the part of the body affected or injured by this occurrence healthy

before the occurrence? If not, give details?

Medical Attention/history – similar or related previous events

4. Is the present injury or disability totally attributable to this occurrence? If

not, give details:

5. Give details of any similar injury or disability prior to this occurrence:

4. Name & address of usual medical practitioner, and any person who has

treated you for a similar disability:

Other or previous claims

1. Is compensation being claimed from any other source?

Yes/No

If so, from whom? …………………………..………….…

…………………………………………………………………………………………………………………………………………………………………………..

2. Give details of similar or related previous workers’ compensation claims

Name & address of

Name of Insurer

Nature of injury, disease

employer

(if known)

or other claim

Injured worker’s declaration

I solemnly and sincerely declare that each and every answer above and the particulars contained herein or annexed hereto relating to myself and the occurrence are true

both in substance and in fact to the best of my knowledge and belief. I take notice that, under the provisions of section 59 (2) of the Workers’ Compensation and

Rehabilitation Act 1981, I am required to notify my employer in writing within 7 days if I commence work with another employer after making a claim, or while receiving

weekly payments of workers’ compensation. I understand that I can only claim damages at common law for my injury against my employer if it is agreed or determined

that my degree of disability is not less than 16%. I also understand if my disability is assessed to be not less than 16% but less than 30% I must make an election to

access common law and this must be made within the time specified in the Workers’ Compensation and Rehabilitation Act 1981 (which in most cases is six months after

the commencement of weekly compensation payments) however, this requirement does not apply if I have a disability of 30% or more.

Dated this ………………………………………………….……….

day of ………………………………………………………..

Year …………………….

Signature of worker ………………………………………………………………..……… Signature of witness ………………………………………………..

Consent Authority (to be signed at the option of the worker) I authorise any doctor who treats me (whether named in this certificate or not)

to discuss my medical condition, in relation to my claim for workers’ compensation and return to work options, with my employer and

with their insurer.

Dated this ………………………………………………….……….

day of ………………………………………………………..

Year …………………….

Signature of worker ………………………………………………………………..……… Signature of witness ………………………………………………..

IMPORTANT: FAILURE TO PROVIDE YOUR SIGNATURE ON EITHER THE DECLARATION OR THE AUTHORITY ABOVE MAY DELAY A

DECISION BY THE INSURER ON YOUR CLAIM.

Privacy Amendment (Private Sector) Act 2000

I consent to my employer’s insurer and its appointed service providers collecting personal information, inclusive of sensitive information such as

medical information, about me and using it for the purpose of assessing and managing my worker’s compensation claim, including determining

liability and whether my claim is true. This consent extends to my employers’ insurer disclosing my personal information, inclusive of sensitive

information, to other insurers, medical practitioners, rehabilitation providers, investigators, legal practitioners and other experts or consultants for the

purpose of assessing and managing my claim. My personal information, inclusive of sensitive information, may also be disclosed as require dor

permitted by Law. I also consent to my employers’ insurer disclosing my personal details to the WorkCover WA which is authorised to use this

information to fulfil it’s functions and obligations under the Workers’ Compensation and Rehabilitation Act 1981.

I have read the Privacy and Your Information Section and I consent to the Insurer dealing with my personal information in that manner.

Signed: …………………….……………………….……….……… Date: ………………………….…………………………………………….….………

Name: ……………………………………………………….…….

Witness: (name & signature) ……………..…………………………………………