New South Wales Government

Please complete the form below. Mandatory fields are marked ¤

Notifier

1. ¤ Notifier Name:
2. ¤ Phone Number:
3. ¤ Email Address:
4. ¤ Relationship to worker:
5. Address

   1. ¤ Notifier Mail Address Line 1:
   2. Notifier Mail Address Line 2:
6. Suburb:
7. State: New South Wales Victoria Tasmania Western Australia South Australia Queensland Australian Capital Territory Northern Territory Other
8. Other:
9. Postcode:
10. Country:

Contact person

1. ¤ Ref #:
2. ¤ Worker:
3. Address

   1. ¤ Worker Address Line 1:
   2. Worker Address Line 2:
4. Suburb:
5. State: New South Wales Victoria Tasmania Western Australia South Australia Queensland Australian Capital Territory Northern Territory Other
6. Other:
7. Postcode:
8. Country:
9. ¤ Worker DOB
   (e.g. 15/05/1977):
10. ¤ Date of Injury
    (e.g. 26/02/2006):
11. ¤ Insurer:
12. ¤ Claim No.:

Employer

1. ¤ Business Name:
2. Address

   1. ¤ Address Line 1:
   2. Address Line 2:
3. Suburb:
4. State: New South Wales Victoria Tasmania Western Australia South Australia Queensland Australian Capital Territory Northern Territory Other
5. Other:
6. Postcode:
7. Country:
8. ¤ ABN:

Details

1. ¤ What is the nature of your matter ?: S60 Expenses S66/67 Benefits Weekly Compensation Benefits Other
2. Specify:
3. ¤ When was the initial contact date?
   (e.g. 30/12/2006):
4. ¤ What documents were supplied in relation to each of the above issues:
5. ¤ Outline all dates including the last date that you made contact with the agent in relation to each of the above issues:
6. ¤ Has the insurer provided you with a reply in relation to the above issues?
   Yes

   No
7. Do you wish to, or have your attempted to make an application with the WCC ?
   Yes

   No
8. Notes:

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