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PO Box 322
Burnie TAS 7320
Ph: (03) 64311888
Fax: (03) 64313444
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Workers Compensation First Contact
Injured Worker Details:
Full Name:
Home Address:
Home Phone:
Mobile:
Email:
Normal Weekly Earnings:
Employer Details:
Full Business Name:
Business Phone:
Business Address:
Business Email:
Contact Person:
-- Please select --
QBE
CGU
Allianz
Other
Insurer:
Policy Number:
Person Making Notification:
Name:
Contact Phone:
Contact Email:
Relationship to injured worker:
Medical / Injury Details:
Accident Description
Date Employer Notified:
Date of Injury:
Address (Where injury occured):
How did injury occur:
Injury Description
Describe Injury / Condition:
-- Please select --
Yes
No
-- Please select --
Yes
No
Currently Off Work:
Anticipate more than 7 days incapacity:
Treating Doctor (Name):
Treating Doctor (Phone):
First Treatment Date:
Hospital/Practice (Name):
Workers Compensation First Contact Form
(inc. Suburb, postcode):
(inc. Suburb, postcode):
DOB:
Note: When submitting this form a copy will be sent to Saunders Higgins and also to the email address you provide in the "Person Making Notification" contact email field.