This section includes forms required for claims, disputes and general administrative processes within the scheme.
If you require help when filling out any forms, please contact Advice and Assistance on 1300 794 744.
To order any of our publications please complete the Publications Order Form (Word or Fillable PDF) and send to communications@workcover.wa.gov.au
Fact Sheet – Who is WorkCover WA? (Accessible PDF – 585KB)
This fact sheet outlines the role of WorkCover WA in the workers’ compensation and injury management scheme.
- Workers’ Compensation Claim Form (PDF – 101KB) (Fillable PDF – 1MB)
The claim form includes information on the claims process and your rights, responsibilities and entitlements when making a claim for workers’ compensation.
- Handy Hints Brochure (PDF – 370KB)
This comprehensive guide to the Workers’ Compensation Claim Form will help you complete each section of the form.
Claim form for dependants of deceased workers
Dependants of deceased workers should refer to Workplace fatality claims for further information about making a claim.
- Form 34: Election to Retain the Right to Seek Damages (Word – 67kb)
This form is used when you are pursuing a common law claim against your employer.
- Form AMS 1: Request for Assessment by AMS of Degree of Permanent Impairment (Word – 50kb)
This form is used when requesting an Approved Medical Specialist to assess the degree of your permanent impairment.
- Workplace Rehabilitation Referral Form (Word – 99kb)
This form can be used by workers, employers or treating medical practitioners to request a referral to a workplace rehabilitation provider.
- Form 6: Declaration of worker not residing in Western Australia (Word – 26kb, Fillable PDF – 136kb)
This form is used to declare an injured workers’ incapacity when the injured worker does not reside in Western Australia.
- Form 21: Notice of Dispute (noise induced hearing loss) (Word – 120kb)
This form can be used by workers or employers when disputing the results of an audiometric (hearing) test.
- Form 406: Authorisation to Release WorkCover WA Audiometric Test Results (Word – 98kb)
Form used by workers to authorise the release of their audiometric test results to whoever they specify.
- Form 412: Worker’s Consent to Release Hearing Test Results (PDF – 195kb)
This form can be used by a worker to authorise WorkCover WA to release their hearing test(s) results to a nominee.
Workers’ Compensation and Injury Management Conciliation Rules 2011 (External Link)
The Conciliation Rules support the arrangements for resolving workers’ compensation disputes in Western Australia. All parties to a dispute need to comply with the Conciliation Rules.
Conciliation forms
Online lodgement
WorkCover WA provides an online lodgement facility for submitting applications for conciliation. An electronically writeable and printable version of the Form 100 – Application for Conciliation for use by unrepresented workers or uninsured employers, or when the online system is unavailable, is below.
Forms
Please note all forms need to be printed single-sided. Forms may be printed and completed by hand or electronically filled.
- Form 100 – Application for Conciliation (PDF – 404kb)
- Form 101 – Statement of Social and Financial Circumstances (PDF – 370kb)
- Form 103 – Application for Order for Insurer to Make Payment (PDF – 266kb)
- Form 104 – Notice of Representation (PDF – 244kb)
- Form 105 – Multiple Respondent Form (PDF – 266kb)
- Form 106 – Notice of Discontinuance (PDF – 210kb)
- Form 107 – Memorandum of Consent to Finalising Order (PDF – 242kb)
- Form 108 – Application for Order and/or Assessment of Costs (PDF – 274kb)
Workers’ Compensation and Injury Management Arbitration Rules 2011 (External Link)
The Arbitration Rules support the arrangements for resolving workers’ compensation disputes in Western Australia. All parties to a dispute need to comply with the Arbitration Rules.
Arbitration forms
Online lodgement
WorkCover WA provides an online lodgement facility for submitting applications for arbitration. An electronically writeable and printable version of the appropriate application form for use by unrepresented workers, unrepresented dependants or uninsured employers, or when the online system is unavailable, is below.
Forms
Please note all forms need to be printed single-sided. Forms may be printed and completed by hand or electronically filled.
- Form 150 – Application for Arbitration (PDF – 480kb)
- Form 150A – Application for Arbitration – Workplace Fatality (PDF – 330kb)
- Form 152 – Application to Extend Time to Lodge an Application for Arbitration (PDF – 297kb)
- Form 153 – Statement of Social and Financial Circumstances (PDF – 372kb)
- Form 154 – Reply to an Application for Arbitration (PDF – 341kb)
- Form 155 – Certificate of Service (PDF – 303kb)
- Form 156 – Interlocutory Application (PDF – 296kb)
- Form 156A – Notice Consenting or Opposing Interlocutory Application (PDF – 263kb)
- Form 157 – Memorandum of Consent Order (PDF – 905kb)
- Form 158 – Order for Production of Documents or Material (PDF – 294kb)
- Form 159 – Summons to Witness (PDF – 251kb)
- Form 161 – Multiple Respondent Form (PDF – 233kb)
- Form 162 – Notice of Representation (PDF – 245kb)
- Form 163 – Notice of Discontinuance (PDF – 255kb)
- Form 164 – Application for Order and/or Assessment of Costs (PDF – 268kb)
- Form 164A – Notice Consenting or Opposing Application for Order and/or Assessment of Costs (PDF – 265kb)
Prescribed forms
Certain forms are prescribed by the Workers’ Compensation and Injury Management Regulations 1982.
As prescribed forms, their format cannot be altered. Where a form is required at a particular stage in the process, it should be filled out in the format provided.
- Form 1 – Election for Schedule 2 injuries under Part III Division 2 (PDF – 20kb)
- Form 1A – Election for Schedule 2 injuries under Part III Division 2A (PDF – 20kb)
- Form 15C – Memorandum of Agreement (PDF – 203kb)
- Form 15D – Statement of the consequences of the recording of a Memorandum of Agreement (PDF – 20kb)
- Form 15E – Notice disputing Memorandum of Agreement, or objecting to its being recorded (PDF – 70kb)
- Workers’ Compensation and Injury Management: A Guide for Workers (PDF – 6.44MB)
A comprehensive guide to assist you through the workers’ compensation process, injury management and return to work.
- Fact sheet – Uninsured Workers’ Compensation Claims (PDF – 243KB)
This fact sheet provides an overview of WorkCover WA’s process for a workers’ compensation claim when an employer did not hold insurance and, the consequences of not having insurance.
- Fact sheet – Uninsured Workers’ Compensation Claims – Mandarin (PDF – 243KB)
This fact sheet has been translated to Mandarin.
- A Guide to Noise Induced Hearing Loss (PDF – 595 kb)
A comprehensive guide on your obligations regarding noise induced hearing loss.
- Work related hearing loss claims – Employer and worker fact sheet (PDF – 595 kb)
A fact sheet that outlines the process of claims for noise induced hearing loss for workers and employers.
- NIHL Directory of Service Providers (Word – 193kb)
A directory of approved hearing testers in Western Australia.
- A Technical Note on Contractors and Workers’ Compensation (PDF – 430kb)
Detailed information to clarify liability and legal obligations in relation to contractors and sub-contractors.
- Silicosis Fact Sheet for Workers (PDF – 175KB)
This fact sheet provides information on setting out the process for making a compensation claim for workers with a provisional or confirmed diagnosis of silicosis, and the responsibility of insurers where a claim has been made. - Silicosis Fact Sheet for Workers(Simplified Chinese 简体中文) (PDF – 156KB)
- Silicosis Fact Sheet for Workers(Tagalog) (PDF – 102KB)
- Silicosis Fact Sheet for Workers (Pashto) (PDF – 103KB)
- Template Injury Management System (Word – 52kb)
This template will assist employers to devise an appropriate injury management system for their workplace.
- Template Return to Work Program (Word – 108kb)
This template will assist employers to devise an appropriate Return to Work Program collaboratively with the injured worker.
- Workplace Rehabilitation Referral Form (Word – 99kb)
This form can be used by workers, employers or treating medical practitioners to request a referral to a workplace rehabilitation provider.
- Form 6: Declaration of worker not residing in Western Australia (Word – 26kb, Fillable PDF – 136kb)
This form is used to declare an injured workers’ incapacity when the injured worker does not reside in Western Australia.
- Form 18: Notice of Arrangement of Audiometric Test (Word – 308kb)
This form is used to notify a worker that an audiometric test has been arranged including the appointment details and pre-appointment requirements of the worker.
- Form 410: Request for Baseline Full Audiological Assessment (Word – 50kb)
Form used by employers to request a full audiological assessment of a worker.
- Form 21: Notice of Dispute (noise induced hearing loss) (Word – 120kb)
This form can be used by workers or employers when disputing the results of an audiometric (hearing) test.
- Form 406: Authorisation to Release WorkCover WA Audiometric Test Results (Word – 98kb)
Form used by workers to authorise the release of their audiometric test results to whoever they specify.
- Form 412: Worker’s Consent to Release Hearing Test Results (PDF – 195kb)
This form can be used by a worker to authorise WorkCover WA to release their hearing test(s) results to a nominee.
- Form 15G: Notice of Intention to Dismiss a Worker (PDF – 270kb)
This form is required if you intend to dismiss an injured worker within 12 months from the day the worker is entitled to receive weekly payments.
Workers’ Compensation and Injury Management Conciliation Rules 2011 (External Link)
The Conciliation Rules support the arrangements for resolving workers’ compensation disputes in Western Australia. All parties to a dispute need to comply with the Conciliation Rules.
Conciliation forms
Online lodgement
WorkCover WA provides an online lodgement facility for submitting applications for conciliation. An electronically writeable and printable version of the Form 100 – Application for Conciliation for use by unrepresented workers or uninsured employers, or when the online system is unavailable, is below.
Forms
Please note all forms need to be printed single-sided. Forms may be printed and completed by hand or electronically filled.
- Form 100 – Application for Conciliation (PDF – 404kb)
- Form 101 – Statement of Social and Financial Circumstances (PDF – 370kb)
- Form 103 – Application for Order for Insurer to Make Payment (PDF – 266kb)
- Form 104 – Notice of Representation (PDF – 244kb)
- Form 105 – Multiple Respondent Form (PDF – 266kb)
- Form 106 – Notice of Discontinuance (PDF – 210kb)
- Form 107 – Memorandum of Consent to Finalising Order (PDF – 242kb)
- Form 108 – Application for Order and/or Assessment of Costs (PDF – 274kb)
Workers’ Compensation and Injury Management Arbitration Rules 2011 (External Link)
The Arbitration Rules support the arrangements for resolving workers’ compensation disputes in Western Australia. All parties to a dispute need to comply with the Arbitration Rules.
Arbitration forms
Online lodgement
WorkCover WA provides an online lodgement facility for submitting applications for arbitration. An electronically writeable and printable version of the appropriate application form for use by unrepresented workers, unrepresented dependants or uninsured employers, or when the online system is unavailable, is below.
Forms
Please note all forms need to be printed single-sided. Forms may be printed and completed by hand or electronically filled.
- Form 150 – Application for Arbitration (PDF – 480kb)
- Form 150A – Application for Arbitration – Workplace Fatality (PDF – 330kb)
- Form 152 – Application to Extend Time to Lodge an Application for Arbitration (PDF – 297kb)
- Form 153 – Statement of Social and Financial Circumstances (PDF – 372kb)
- Form 154 – Reply to an Application for Arbitration (PDF – 341kb)
- Form 155 – Certificate of Service (PDF – 303kb)
- Form 156 – Interlocutory Application (PDF – 296kb)
- Form 156A – Notice Consenting or Opposing Interlocutory Application (PDF – 263kb)
- Form 157 – Memorandum of Consent Order (PDF – 905kb)
- Form 158 – Order for Production of Documents or Material (PDF – 294kb)
- Form 159 – Summons to Witness (PDF – 251kb)
- Form 161 – Multiple Respondent Form (PDF – 233kb)
- Form 162 – Notice of Representation (PDF – 245kb)
- Form 163 – Notice of Discontinuance (PDF – 255kb)
- Form 164 – Application for Order and/or Assessment of Costs (PDF – 268kb)
- Form 164A – Notice Consenting or Opposing Application for Order and/or Assessment of Costs (PDF – 265kb)
Prescribed forms
Certain forms are prescribed by the Workers’ Compensation and Injury Management Regulations 1982.
As prescribed forms, their format cannot be altered. Where a form is required at a particular stage in the process, it should be filled out in the format provided.
- Form 1 – Election for Schedule 2 injuries under Part III Division 2 (PDF – 20kb)
- Form 1A – Election for Schedule 2 injuries under Part III Division 2A (PDF – 20kb)
- Form 15C – Memorandum of Agreement (PDF – 203kb)
- Form 15D – Statement of the consequences of the recording of a Memorandum of Agreement (PDF – 20kb)
- Form 15E – Notice disputing Memorandum of Agreement, or objecting to its being recorded (PDF – 70kb)
- Workers Compensation: A Guide for Employers (PDF – 8MB)
A comprehensive guide to assist you with your workers’ compensation and injury management obligations in accordance with the Workers’ Compensation and Injury Management Act 1981.
- Injury Management: A Guide for Employers (PDF – 1MB)
This publication provides information regarding your legal obligations for injury management systems and Return to Work Programs and contains a three step approach to effective injury management.
- Workers’ compensation essentials – Employer fact sheet (PDF – 1.8MB)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- Những điều cần biết về bồi thường nhân viên – Tờ thông tin dành cho chủ doanh nghiệp – (PDF – 2,285KB)
- Workers’ compensation essentials – Employer fact sheet (Vietnamese)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- أساسيات تعويض العمال ورقة معلومات لجهة العمل (PDF – 2,320KB)
- Workers’ compensation essentials – Employer fact sheet (Arabic)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- 工伤赔偿须知雇主参阅资料 (2,372KB)
- Workers’ compensation essentials – Employer fact sheet (Chinese Simplified for Mandarin) (PDF – 2,405KB)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- 工伤赔偿须知雇主参阅资料 (2,393)
- Workers’ compensation essentials – Employer fact sheet (Chinese Traditional for Cantonese)
- This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- ਕਰਮਚਾਰੀਆਂ ਦੇ ਮੁਆਵਜ਼ੇ ਲਈ ਜ਼ਰੂਰੀ ਗੱਲਾਂ – ਕਰਮਚਾਰੀਆਂ ਲਈ ਤੱਥ ਸੂਚੀ – (PDF – 2,307KB)
- Workers’ compensation essentials – Employer fact sheet (Punjabi)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- Mahahalagang impormasyon sa bayad-pinsala para sa mga manggagawa – Fact sheet ng taga-empleyo –
- Workers’ compensation essentials – Employer fact sheet (Tagalog) (PDF – 2,271KB)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- Injured at work poster – For employers with insurers (PDF – 115KB)
This A3 poster has been produced for employers who have a workers’ compensation insurance policy with an insurer and outlines what your worker can do if they are injured at work.
- Injured at work poster – For self-insurers (PDF – 115KB)
This A3 poster has been produced for employers who are approved by WorkCover WA to self-insure and outlines what your workers can do if they are injured at work.
- Fact sheet – Supporting your worker (PDF – 219kb)
This fact sheet details the steps an employer can take to assist their worker to return to work.
- Fact sheet – Case Conferences (Fillable PDF – 535kb)
This fact sheet outlines how a case conference can assist all parties involved in a claim to help an injured worker return to work.
- A Technical Note on Contractors and Workers’ Compensation (PDF – 430kb)
Detailed information to clarify liability and legal obligations in relation to contractors and sub-contractors.
- A Guide to Noise Induced Hearing Loss (PDF – 595 kb)
A comprehensive guide on your obligations regarding noise induced hearing loss.
- Work related hearing loss claims – Employer and worker fact sheet (PDF – 595 kb)
A fact sheet that outlines the process of claims for noise induced hearing loss for workers and employers.
- NIHL Directory of Service Providers (Word – 193kb)
A directory of approved hearing testers in Western Australia.
- Info Sheet: Who Covers Interstate Employees for Workers’ Compensation? (PDF – 433Kb)
This fact sheet provides information to clarify your obligations in relation to workers based in another state or territory.
- Workers not residing in Western Australia – Fact Sheet (PDF – 402KB)
This fact sheet explains how coverage works for workers not residing in Western Australia.
Workers’ Compensation and Injury Management Conciliation Rules 2011 (External Link)
The Conciliation Rules support the arrangements for resolving workers’ compensation disputes in Western Australia. All parties to a dispute need to comply with the Conciliation Rules.
Conciliation forms
Online lodgement
WorkCover WA provides an online lodgement facility for submitting applications for conciliation. An electronically writeable and printable version of the Form 100 – Application for Conciliation for use by unrepresented workers or uninsured employers, or when the online system is unavailable, is below.
Forms
Please note all forms need to be printed single-sided. Forms may be printed and completed by hand or electronically filled.
- Form 100 – Application for Conciliation (PDF – 404kb)
- Form 101 – Statement of Social and Financial Circumstances (PDF – 370kb)
- Form 103 – Application for Order for Insurer to Make Payment (PDF – 266kb)
- Form 104 – Notice of Representation (PDF – 244kb)
- Form 105 – Multiple Respondent Form (PDF – 266kb)
- Form 106 – Notice of Discontinuance (PDF – 210kb)
- Form 107 – Memorandum of Consent to Finalising Order (PDF – 242kb)
- Form 108 – Application for Order and/or Assessment of Costs (PDF – 274kb)
Workers’ Compensation and Injury Management Arbitration Rules 2011 (External Link)
The Arbitration Rules support the arrangements for resolving workers’ compensation disputes in Western Australia. All parties to a dispute need to comply with the Arbitration Rules.
Arbitration forms
Online lodgement
WorkCover WA provides an online lodgement facility for submitting applications for arbitration. An electronically writeable and printable version of the appropriate application form for use by unrepresented workers, unrepresented dependants or uninsured employers, or when the online system is unavailable, is below.
Forms
Please note all forms need to be printed single-sided. Forms may be printed and completed by hand or electronically filled.
- Form 150 – Application for Arbitration (PDF – 480kb)
- Form 150A – Application for Arbitration – Workplace Fatality (PDF – 330kb)
- Form 152 – Application to Extend Time to Lodge an Application for Arbitration (PDF – 297kb)
- Form 153 – Statement of Social and Financial Circumstances (PDF – 372kb)
- Form 154 – Reply to an Application for Arbitration (PDF – 341kb)
- Form 155 – Certificate of Service (PDF – 303kb)
- Form 156 – Interlocutory Application (PDF – 296kb)
- Form 156A – Notice Consenting or Opposing Interlocutory Application (PDF – 263kb)
- Form 157 – Memorandum of Consent Order (PDF – 905kb)
- Form 158 – Order for Production of Documents or Material (PDF – 294kb)
- Form 159 – Summons to Witness (PDF – 251kb)
- Form 161 – Multiple Respondent Form (PDF – 233kb)
- Form 162 – Notice of Representation (PDF – 245kb)
- Form 163 – Notice of Discontinuance (PDF – 255kb)
- Form 164 – Application for Order and/or Assessment of Costs (PDF – 268kb)
- Form 164A – Notice Consenting or Opposing Application for Order and/or Assessment of Costs (PDF – 265kb)
Certain forms are prescribed by the Workers’ Compensation and Injury Management Regulations 1982.
As prescribed forms, their format cannot be altered. Where a form is required at a particular stage in the process, it should be filled out in the format provided.
- Form 1 – Election for Schedule 2 injuries under Part III Division 2 (PDF – 20kb)
- Form 1A – Election for Schedule 2 injuries under Part III Division 2A (PDF – 20kb)
- Form 15C – Memorandum of Agreement (PDF – 203kb)
- Form 15D – Statement of the consequences of the recording of a Memorandum of Agreement (PDF – 20kb)
- Form 15E – Notice disputing Memorandum of Agreement, or objecting to its being recorded (PDF – 70kb)
- Guide to the Workers’ Compensation Conciliation Service (PDF – 391kb)
This guide outlines how to commence conciliation and what to expect during the process.
- Information and Guidelines: Communication with Workers’ Compensation Conciliation Service (PDF – 145kb)
- What happens if there is a dispute? (PDF – 1.36MB)
This publication provides an overview of the dispute resolution processes provided by WorkCover WA.
- Guide to the Workers’ Compensation Arbitration Service (PDF – 1.57MB)
This guide outlines how to commence arbitration and what to expect during the process.
- Arbitration Online External User Guide (PDF – 1.7MB)
- What happens if there is a dispute? (PDF – 1.36MB)
This publication provides an overview of the dispute resolution processes provided by WorkCover WA.
General practitioners perform an integral function in progressing the medical forms for workers’ compensation claims.
General practitioners and medical practitioners are encouraged to use WorkCover WA’s gpsupport website to access a number of supporting resources.
First Certificate of Capacity
- First Certificate of Capacity (PDF – 175kb)
- Explanatory notes – First Certificate of Capacity (PDF – 241kb)
Progress Certificate of Capacity
- Progress Certificate of Capacity (PDF – 187kb)
- Explanatory notes – Progress Certificate of Capacity (PDF – 409kb)
Final Certificate of Capacity
- Final Certificate of Capacity (PDF – 156kb)
- Explanatory notes – Final Certificate of Capacity (PDF – 238kb)
The Clinical Framework for the Delivery of Health Services (Clinical Framework) is an evidence-based guide designed to support healthcare practitioners delivering services to people with compensable injuries. Developed by the Transport Accident Commission (TAC) and the Victorian WorkCover Authority, this framework reflects contemporary research and has been widely endorsed by Australian workers’ compensation jurisdictions, as well as peak health associations.
- Clinical Framework for the Delivery of Health Services (PDF – 1324kb)
WorkCover WA endorses the use of the Clinical Framework by medical and allied health practitioners delivering services to injured workers in Western Australia.
The Clinical Framework outlines five principles shown to deliver optimal recovery and return to work outcomes for injured workers. The principles are:
- measure and demonstrate the effectiveness of treatment
- adopt a biopsychosocial approach
- empower the injured person to manage their injury
- implement goals focused on optimising function, participation and return to work
- base treatment on best available research evidence
We encourage you to use and share the framework with your colleagues, patients (injured workers), employers and workplace rehabilitation providers in working towards optimal outcomes in recovery and return to work.
- Form AMS 1: Request for Assessment by AMS of Degree of Permanent Impairment (Word – 50kb)
This form is used when requesting an Approved Medical Specialist to assess the degree of your permanent impairment.
- Form AMS 2: Requirement for Worker to Attend before an Approved Medical Specialist (Word – 50kb)
This form indicates a requirement to attend an impairment assessment. There are penalties if a worker fails to attend as required.
- Form AMS 3: Requirement to Produce Relevant Documents or Information for an Impairment Assessment (Word – 50kb)
This form is used when an approved medical specialist requires a worker, employer or employer’s insurer to produce relevant documents and information to assist in the impairment assessment. The worker, employer or employer’s insurer must provide relevant documents or information to the approved medical specialist.
- Form AMS 4: Requirement to Consent to Another Party to Produce Relevant Documents or Information for an Impairment Assessment (Word – 50kb)
This form is used by an approved medical specialist when they require consent from the worker, employer or employer’s insurer, for another party to provide relevant documents or information required for the impairment assessment.
- Form AMS 4A: Requirement to Produce Information for an Impairment Assessment (Word – 50kb)
This form is used after an impairment assessment examination, when additional information is required from the worker.
- Form AMS 5: Report on Evaluation of Degree of Permanent Impairment (Word – 130kb)
The approved medical specialist is to produce a detailed Form AMS 5 and forward a copy to both the worker and employer alongside a Form AMS 6.
- Form AMS 6: Certificate of Degree of Permanent Impairment (Word – 50kb)
The approved medical specialist must forward this certificate alongside the Form AMS 5.
- Form AMS 6A: PIRs Rating (Word – 47kb)
Form AMS 5 and 6 may have the PIRs Rating Form attached when a psychological injury is being assessed.
- Form AMS 7: Report on Workers Condition Not Stabilised (Word – 50kb)
The approved medical specialist uses this form when the worker has been assessed, but their injury has not stabilised to the extent required by the Act and the WorkCover WA Guides for the Evaluation of Permanent Impairment. The approved medical specialist is to forward this report to both the worker and the employer alongside Form AMS 8.
- Form AMS 8: Certificate Where Workers Condition Not Stabilised (Word – 50kb)
The approved medical specialist is to forward this certificate to both the worker and the employer alongside Form AMS 7.
- Notice about special evaluations – on or after 12 October 2020 (PDF – 580kb)
- WorkCover WA Guidelines for the Evaluation of Permanent Impairment, fourth edition (PDF 652KB)
This guide is used by Approved Medical Specialists when evaluating the degree of an injured worker’s permanent impairment.
- WorkCover WA Guidance Notes for Approved Medical Specialists Procedures for the permanent impairment assessment process (PDF – 1MB)
Outlines the methodology, process and terminology of the impairment assessment process.
- Fact Sheet: Assessment of Permanent Injuries before and after 14 November 2005 (PDF – 2MB)
Provides guidance in determining the process to be followed when requesting or undertaking a disability or impairment assessment.
- AMS Application Pack – SPECIALIST – Medical Practitioners (PDF – 325kb)
Information on how to apply to become a specialist AMS medical practitioner.
- AMS Application Pack – NON-SPECIALIST – Medical Practitioners (PDF – 334kb)
Information on how to apply to become a non-specialist AMS medical practitioner.
Register of approved workplace rehabilitation providers (WorkCover WA Online)
A register of all WorkCover WA approved workplace rehabilitation providers (WRPs).
Completed applications should be emailed to records@workcover.wa.gov.au.
Applications to become an approved workplace rehabilitation provider- Guidelines to be approved as a Workplace Rehabilitation Provider (PDF – 294KB)
- Application for Approval as a Workplace Rehabilitation Provider Form (PDF – 318KB)
- Staff Details (PDF – 183KB)
- Renewal application for approval as a workplace rehabilitation provider (PDF – 273KB)
- Staff Details (PDF – 183KB)
- Workplace Rehabilitation Providers Principles and Standards of Practice (Principles and Standards) (PDF – 2.21MB)
The Principles and Standards were developed to outline WorkCover WA’s baseline expectations of WRPs operating in the scheme.
- Principles of Practice for Workplace Rehabilitation Providers (Principles) (PDF – 287KB)
WorkCover WA is a signatory to the Principles developed by the Heads of Workers’ Compensation Authorities, and any organisation seeking to become an approved WRP will need to demonstrate that they conform to the Principles.
Note: “Workplace Rehabilitation” means “Vocational Rehabilitation” as stated in the Workers’ Compensation and Injury Management Act 1981.
The Capability Framework sets out the practices, skills, and behaviours expected of workplace rehabilitation providers in the Western Australia workers’ compensation scheme, on entry to the industry and throughout their career.
This easy to navigate online course is designed to assist WRPs to develop or improve their knowledge of workers’ compensation and the skills required to optimise their performance and client service delivery.
Foundations of Workers’ Compensation: Workplace Rehabilitation Providers
- WorkCover WA Online User Guide – Workplace Rehabilitation Providers (PDF – 437kb)
A user guide for WRPs learning to use WorkCover WA Online.
- Information Sheet – WRP Transition from Rehab Online to WorkCover WA Online (PDF – 427kb)
Information on the transition from Rehab Online to WorkCover WA Online.
- Information Sheet – Workplace Rehabilitation – Worker’s Status at Referral and Closure (PDF – 353kb)
Information on declaring a worker’s status at referral and closure of their workplace rehabilitation.
- Information Sheet – Workplace Rehabilitation – Closure Reasons (PDF – 340kb)
Information on valid reasons for closing a workers’ workplace rehabilitation program.
- Form 310: Workplace Rehabilitation Referral (Word – 35kb)
Form used when referring an injured worker to a WRP.
- Form 311: Service Delivery Plan (Word – 40kb)
Form used when developing a service delivery plan.
- Form 312: Workplace Rehabilitation Referral Closure (Word – 40kb)
Form used when closing a worker’s workplace rehabilitation program.
- Consent Form (Word – 38kb)
A form that assists WRPs in advising workers of their rights, responsibilities and conflicts of interest.
- Referral Checklist (Word – 39kb)
A checklist of items that need to be completed upon a worker’s referral to your organisation.
- Initial Assessment Report (Word – 37kb)
The report completed at commencement of a worker’s rehabilitation to assess their current health.
- Progress Report (Word – 33kb)
The report that’s completed throughout a worker’s rehabilitation to track their progress.
- Closure Report (Word – 33kb)
The report that’s completed upon closure of a worker’s workplace rehabilitation.
- NIHL Directory of Service Providers (Word – 193kb)
A directory of approved hearing testers in Western Australia.
Forms
- Form 19A: Report of Baseline Audiometric Test (Word – 48kb)
Form used to report a baseline hearing test for workers commencing employment in prescribed workplaces.
- Form 19B: Report of Subsequent Audiometric Test (Word – 128kb)
Form used to report subsequent hearing tests for workers in prescribed workplaces.
- Form 407: Noise Induced Hearing Loss Audiometer Calibration (Word – 94kb)
Form used to verify audiometer calibration is WorkCover WA approved.
- Form 408: Noise Induced Hearing Loss Audiometric Booth Assessment (Word – 131kb)
Form used to assess an audiometric booth.
- Form 409: Worker Requires a Baseline Full audiological Assessment (Word – 43kb)
Form used to notify an employer that their worker requires a baseline full audiological assessment.
- Form 411: NIHL Audiogram Results (Word – 44kb)
Form used to provide results of an audiogram.
- Form 18: Notice of Arrangement of Audiometric Test (Word – 308kb)
This form is used to notify a worker that an audiometric test has been arranged including the appointment details and pre-appointment requirements of the worker.
- Form 410: Request for Baseline Full Audiological Assessment (Word – 50kb)
Form used by employers to request a full audiological assessment of a worker.
- Form 21: Notice of Dispute (noise induced hearing loss) (Word – 120kb)
This form can be used by workers or employers when disputing the results of an audiometric (hearing) test.
- Form 406: Authorisation to Release WorkCover WA Audiometric Test Results (Word – 98kb)
Form used by workers to authorise the release of their audiometric test results to whoever they specify.
- Form 412: Worker’s Consent to Release Hearing Test Results (PDF – 195kb)
This form can be used by a worker to authorise WorkCover WA to release their hearing test(s) results to a nominee.
- Approved hearing testers – Fact Sheet (PDF – 115kb)
A fact sheet developed to educate approved hearing testers of their responsibilities in the scheme.
- Noise Induced Hearing Loss – Audiometric Officer Testing Manual (PDF – 436kb)
A testing manual designed for audiometric officers that demonstrates the steps taken during an audiometric test.
- Hearing Tester Registration and Testing Requirements – Fact Sheet (PDF – 131kb)
A fact sheet outlining the registration and testing requirements of approved hearing testers.
- NIHL Learning Module (PDF – 479kb)
A learning module developed to assist with the assessment of hearing testers seeking approval from WorkCover WA.
- Fact sheet – Case Conferences (Fillable PDF – 535kb)
This fact sheet outlines how a case conference can assist all parties involved in a claim to help an injured worker return to work.
The Principles and Standards outline WorkCover WA’s baseline expectations of insurers and self-insurers operating in the scheme.
- Insurer and Self-insurer Principles and Standards of Practice (PDF – 4.36MB, Accessible Word Version – 43.8kb)
An interactive self-assessment tool to assist case managers reflect on their practices and processes in adherence to the Principles and Standards.
The Claims Managers Capability Framework sets out the practices, skills and behaviours expected of claims managers in the Western Australia workers’ compensation scheme.
The Capability Framework translates the Insurer and Self-insurer Principles and Standards of Practice into observable practices and behaviours which claims managers should demonstrate when delivering scheme services.
Claims Managers Capability Framework (PDF – 473kb)
The Clinical Framework for the Delivery of Health Services (Clinical Framework) is an evidence-based guide designed to support healthcare practitioners delivering services to people with compensable injuries. Developed by the Transport Accident Commission (TAC) and the Victorian WorkCover Authority, this framework reflects contemporary research and has been widely endorsed by Australian workers’ compensation jurisdictions, as well as peak health associations.
- Clinical Framework for the Delivery of Health Services (PDF – 1324kb)
WorkCover WA endorses the use of the Clinical Framework by medical and allied health practitioners delivering services to injured workers in Western Australia.
The Clinical Framework outlines five principles shown to deliver optimal recovery and return to work outcomes for injured workers. The principles are:
- measure and demonstrate the effectiveness of treatment
- adopt a biopsychosocial approach
- empower the injured person to manage their injury
- implement goals focused on optimising function, participation and return to work
- base treatment on best available research evidence
We encourage you to use and share the framework with your colleagues, patients (injured workers), employers and workplace rehabilitation providers in working towards optimal outcomes in recovery and return to work.
- Q2 Specification Part 1 Version 1.2 (PDF – 1.4MB)
- Q2 Specification Part 2 Version 1.2.1 (PDF – 1.0MB)
WorkCover WA requires additional data from insurers for monitoring scheme performance and setting recommended premium rates. This data is required to be submitted in accordance to the guidelines. Please note, with exception of WC20-Semi-Annual 2022/23 returns, all the Forms are now required to be submitted via WorkCover WA Online. Insurers have the option of emailing the WC20-Semi-Annual 2022/23 returns using the WC20-Semi-Annual Form.
General
Forms
- WC12-Annual-FILE
- WC20-December-FILE
- WC20-Annual-FILE
- WC30-Annual-FILE
- WC20-Semi-Annual (** use for WC20-Semi-Annual 2022/23 Returns)
Guidelines
- Guidelines-WC12-Annual
- Guidelines-WC20-December
- Guidelines-WC20-Annual
- Guidelines-WC30-Annual
- Guidelines-WC20-Semi-Annual
Sample Data
Previous Year's Guidelines
WorkCover WA requires additional data from insurers and self-insurers for monitoring scheme performance and setting recommended premium rates. This data is required to be submitted in accordance to the guidelines. Please note that the WC12 Form is now required to be submitted via WorkCover WA Online.
General
Forms
- Forms and Checklist – Semi-Annual – WC20
- Forms and Checklist – Annual – WC20 & WC30
- Forms – Annual – WC12
Guidelines
WorkCover WA requires additional data from self-insurers for monitoring scheme performance and setting recommended premium rates. This data is required to be submitted in accordance to the guidelines. Please note, with exception of WC20-Semi-Annual 2022/23 returns, all the Forms are now required to be submitted via WorkCover WA Online. Insurers have the option of emailing the WC20-Semi-Annual 2022/23 returns using the WC20-Semi-Annual Form.
General
Forms
- WC20-December-FILE
- WC20-Annual-FILE
- WC31-Annual-FILE
- WC20-Semi-Annual (** use for WC20-Semi-Annual 2022/23 Returns)
Guidelines
Sample Data
Previous Year's Guidelines
WorkCover WA requires additional data from insurers and self-insurers for monitoring scheme performance and setting recommended premium rates. This data is required to be submitted in accordance to the guidelines. Please note that the WC12 Form is now required to be submitted via WorkCover WA Online.
General
Forms
Guidelines
- Standard Employer Indemnity Policy (PDF – 70kb)
The basis of all workers’ compensation policies.
- Checklist for Memoranda of Agreement and 92f Deeds (PDF – 44kb)
Checklist of steps to be taken prior to lodgement of MOA or 92f deeds. -
Guide to completing the Form WC12 (PDF – 489kb)
A guide developed to assist insurers in completing the Form WC12
- Compensation for Workplace Fatality – Guidelines for Insurers/Self-Insurers (PDF – 885kb)
- WF01 – Insurer/self-insurer notice liability is accepted (Word – 20kb)
- WF02 – Insurer/self-insurer notice additional information required (Word – 17kb)
- WF03 – Insurer/self-insurer notice liability is disputed (Word – 21kb)
Insurance Brokers’ Code of Practice (PDF – 905kb)
The Code was developed collaboratively by WorkCover WA and the National Insurance Brokers Association (NIBA) to provide clear guidelines for insurance brokers operating within the workers’ compensation system and assist you to meet your professional obligations.
- Template Injury Management System (Word – 52kb)
This template will assist employers to devise an appropriate injury management system for their workplace.
- Template Return to Work Program (Word – 108kb)
This template will assist employers to devise an appropriate Return to Work Program collaboratively with the injured worker.
- Workplace Rehabilitation Referral Form (Word – 99kb)
This form can be used by workers, employers or treating medical practitioners to request a referral to a workplace rehabilitation provider.
- Form 6: Declaration of worker not residing in Western Australia (Word – 26kb, Fillable PDF – 136kb)
This form is used to declare an injured workers’ incapacity when the injured worker does not reside in Western Australia.
- Form 18: Notice of Arrangement of Audiometric Test (Word – 308kb)
This form is used to notify a worker that an audiometric test has been arranged including the appointment details and pre-appointment requirements of the worker.
- Form 410: Request for Baseline Full Audiological Assessment (Word – 50kb)
Form used by employers to request a full audiological assessment of a worker.
- Form 21: Notice of Dispute (noise induced hearing loss) (Word – 120kb)
This form can be used by workers or employers when disputing the results of an audiometric (hearing) test.
- Form 406: Authorisation to Release WorkCover WA Audiometric Test Results (Word – 98kb)
Form used by workers to authorise the release of their audiometric test results to whoever they specify.
- Form 412: Worker’s Consent to Release Hearing Test Results (PDF – 195kb)
This form can be used by a worker to authorise WorkCover WA to release their hearing test(s) results to a nominee.
- Form 15G: Notice of Intention to Dismiss a Worker (PDF – 270kb)
This form is required if you intend to dismiss an injured worker within 12 months from the day the worker is entitled to receive weekly payments.
- Workers Compensation: A Guide for Employers (PDF – 8MB)
A comprehensive guide to assist you with your workers’ compensation and injury management obligations in accordance with the Workers’ Compensation and Injury Management Act 1981.
- Injury Management: A Guide for Employers (PDF – 1MB)
This publication provides information regarding your legal obligations for injury management systems and Return to Work Programs and contains a three step approach to effective injury management.
- Workers’ compensation essentials – Employer fact sheet (PDF – 1.8MB)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- Những điều cần biết về bồi thường nhân viên – Tờ thông tin dành cho chủ doanh nghiệp – (PDF – 2,285KB)
- Workers’ compensation essentials – Employer fact sheet (Vietnamese)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- أساسيات تعويض العمال ورقة معلومات لجهة العمل (PDF – 2,320KB)
- Workers’ compensation essentials – Employer fact sheet (Arabic)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- 工伤赔偿须知雇主参阅资料 (2,372KB)
- Workers’ compensation essentials – Employer fact sheet (Chinese Simplified for Mandarin) (PDF – 2,405KB)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- 工伤赔偿须知雇主参阅资料 (2,393)
- Workers’ compensation essentials – Employer fact sheet (Chinese Traditional for Cantonese)
- This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- ਕਰਮਚਾਰੀਆਂ ਦੇ ਮੁਆਵਜ਼ੇ ਲਈ ਜ਼ਰੂਰੀ ਗੱਲਾਂ – ਕਰਮਚਾਰੀਆਂ ਲਈ ਤੱਥ ਸੂਚੀ – (PDF – 2,307KB)
- Workers’ compensation essentials – Employer fact sheet (Punjabi)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- Mahahalagang impormasyon sa bayad-pinsala para sa mga manggagawa – Fact sheet ng taga-empleyo –
- Workers’ compensation essentials – Employer fact sheet (Tagalog) (PDF – 2,271KB)
This fact sheet offers essential information to assist employers in meeting their obligations under the Workers’ Compensation and Injury Management Act 1981.
- Injured at work poster – For employers with insurers (PDF – 115KB)
This A3 poster has been produced for employers who have a workers’ compensation insurance policy with an insurer and outlines what your worker can do if they are injured at work.
- Injured at work poster – For self-insurers (PDF – 115KB)
This A3 poster has been produced for employers who are approved by WorkCover WA to self-insure and outlines what your workers can do if they are injured at work.
- Fact sheet – Supporting your worker (PDF – 219kb)
This fact sheet details the steps an employer can take to assist their worker to return to work.
- A Technical Note on Contractors and Workers’ Compensation (PDF – 430kb)
Detailed information to clarify liability and legal obligations in relation to contractors and sub-contractors.
- A Guide to Noise Induced Hearing Loss (PDF – 595 kb)
A comprehensive guide on your obligations regarding noise induced hearing loss.
- Work related hearing loss claims – Employer and worker fact sheet (PDF – 595 kb)
A fact sheet that outlines the process of claims for noise induced hearing loss for workers and employers.
- NIHL Directory of Service Providers (Word – 193kb)
A directory of approved hearing testers in Western Australia.
Register of Registered Agents
See the current list of registered agents.
- How to Apply for Registration or Renewal as a Registered Agent (PDF – 182kb)
This guide explains how to make an application to become registered as an agent.
- Form – Application for Registration or Renewal as a Registered Agent (Word – 94kb)
Application requirements and submission details are contained within this electronically writeable form.
- Workers’ Compensation and Injury Management Regulations 1982 (External Link)
Link to the Regulations on the Legislation website.
- Workers’ Compensation (Legal Practitioners and Registered Agents) Costs Determination 2018 (External link)
Link to the Costs Determination on the Legislation website.
- Independent Registered Agent Activity and Costs Record (Word – 35kb)
This template assists Independent Registered Agents to compile ‘Activity and Costs’ records.
- Independent Registered Agents: Information for Clients (PDF – 145kb)
This fact sheet provides essential information for clients of Independent Registered Agents
- Client Acknowledgement of Costs (Word – 18kb)
This template enables clients to confirm their acknowledgement and awareness of costs related to services provided by Independent Registered Agents.
Workers’ Compensation and Injury Management Conciliation Rules 2011 (External Link)
The Conciliation Rules support the arrangements for resolving workers’ compensation disputes in Western Australia. All parties to a dispute need to comply with the Conciliation Rules.
Conciliation forms
Online lodgement
WorkCover WA provides an online lodgement facility for submitting applications for conciliation. An electronically writeable and printable version of the Form 100 – Application for Conciliation for use by unrepresented workers or uninsured employers, or when the online system is unavailable, is below.
Forms
Please note all forms need to be printed single-sided. Forms may be printed and completed by hand or electronically filled.
- Form 100 – Application for Conciliation (PDF – 404kb)
- Form 101 – Statement of Social and Financial Circumstances (PDF – 370kb)
- Form 103 – Application for Order for Insurer to Make Payment (PDF – 266kb)
- Form 104 – Notice of Representation (PDF – 244kb)
- Form 105 – Multiple Respondent Form (PDF – 266kb)
- Form 106 – Notice of Discontinuance (PDF – 210kb)
- Form 107 – Memorandum of Consent to Finalising Order (PDF – 242kb)
- Form 108 – Application for Order and/or Assessment of Costs (PDF – 274kb)
Workers’ Compensation and Injury Management Arbitration Rules 2011 (External Link)
The Arbitration Rules support the arrangements for resolving workers’ compensation disputes in Western Australia. All parties to a dispute need to comply with the Arbitration Rules.
Arbitration forms
Online lodgement
WorkCover WA provides an online lodgement facility for submitting applications for arbitration. An electronically writeable and printable version of the appropriate application form for use by unrepresented workers, unrepresented dependants or uninsured employers, or when the online system is unavailable, is below.
Forms
Please note all forms need to be printed single-sided. Forms may be printed and completed by hand or electronically filled.
- Form 150 – Application for Arbitration (PDF – 480kb)
- Form 150A – Application for Arbitration – Workplace Fatality (PDF – 330kb)
- Form 152 – Application to Extend Time to Lodge an Application for Arbitration (PDF – 297kb)
- Form 153 – Statement of Social and Financial Circumstances (PDF – 372kb)
- Form 154 – Reply to an Application for Arbitration (PDF – 341kb)
- Form 155 – Certificate of Service (PDF – 303kb)
- Form 156 – Interlocutory Application (PDF – 296kb)
- Form 156A – Notice Consenting or Opposing Interlocutory Application (PDF – 263kb)
- Form 157 – Memorandum of Consent Order (PDF – 905kb)
- Form 158 – Order for Production of Documents or Material (PDF – 294kb)
- Form 159 – Summons to Witness (PDF – 251kb)
- Form 161 – Multiple Respondent Form (PDF – 233kb)
- Form 162 – Notice of Representation (PDF – 245kb)
- Form 163 – Notice of Discontinuance (PDF – 255kb)
- Form 164 – Application for Order and/or Assessment of Costs (PDF – 268kb)
- Form 164A – Notice Consenting or Opposing Application for Order and/or Assessment of Costs (PDF – 265kb)
A party to a dispute in the Workers’ Compensation Arbitration Service may appeal to the District Court of Western Australia against a decision of an Arbitrator. In any other case, leave to appeal may be granted where a question of law is involved.
An appeal to the District Court must be made within 28 days from when the Arbitrator provides the parties with the written reasons for the determination.
The District Court may affirm, vary, quash, substitute or make an addition to the original Arbitrator decision.
Accessing previous decisions
The jurisdiction or authority that deals with appeals depends upon when the appeal was made.
December 2011 - presentAppeals from the Workers’ Compensation Arbitration Service have been heard by the District Court of Western Australia. These decisions can be accessed via the eCourts portal.
Previous decisions of the Commissioner and Compensation Magistrate can now be accessed via WorkCover WA Online. Information about how to register for WorkCover WA Online can be found here.
November 2005 – November 2011
The Commissioner dealt with matters regarding:
- a novel or complex question of law referred by an arbitrator
- a question of law referred by a party to the proceeding before an arbitrator
- appeals against a decision of an arbitrator.
1994 – November 2005
The Compensation Magistrate dealt with:
- a novel or complex question of law referred by a review officer
- a question of law referred by a party to the proceeding before a review officer
- appeals against a decision of a review officer.
- Workers’ Compensation (Legal Practitioners and Registered Agents) Costs Determination 2018 (External link)
Link to the Costs Determination on the Legislation website.
- Fact sheet – Case Conferences (Fillable PDF – 535kb)
This fact sheet outlines how a case conference can assist all parties involved in a claim to help an injured worker return to work.
