WorkCover Claim Form VIC PDF

Instructions

• As a worker, you need to complete questions 1-6 in Part A of this form using a dark blue or black pen
• Sign the authority to release medical information and worker's declaration at question 6. The form cannot be accepted without your signature.
• Give both parts of this form (after you have completed Part A) to your employer as soon as possible after being injured
• Please keep a copy for your records