- 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)
