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

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

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

Employer Please Note

If the First Medical Certificate indicates the injured worker will be absent from the workplace for

more than 3 working days; and/or is unable to return to normal duties;

You must complete this section and fax it to the medical practitioner who provided the worker’s

First Medical Certificate within 2 working days.

DETAILS TO BE PROVIDED TO MEDICAL PRACTITIONER

ATTN: Dr ……………………………………………………

Fax No:

…………………………

WORKER’S DETAILS

Name in full: .........................................................................................................................................

Address: ...............................................................................................................................................

Date of Birth: ………………Occupation:………………………………… Telephone………………..

…..

INSURER’S DETAILS

Name of Insurer:...................................................................................................................................

Contact Person:……………………………………………………………. Telephone:……………………

EMPLOYER’S DETAILS

Trading Name:………………………………………………………………..Telephone:……………………

Address of worker’s usual workplace: ..................................................................................................

Employer contact for liaison with medical practitioner:…………………………………………………….

Role within organisation: ……………………………Telephone:………………….Fax:………………….

ALTERNATIVE DUTIES FOR THE INJURED

WORKER