Worker forms

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.

Assistance

If you are having trouble filling in your claim form, first speak to your employer. If you still have questions, call Advice and Assistance on 1300 794 744.

Claims process

Strict timeframes apply to employers and insurers when a worker has lodged a claim form. For more information, see the Making a claim section.

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 AMS1: 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.

Medical

• 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)
  Form 6: Declaration of worker not residing in Western Australia (Fillable PDF – 136 kb)
  This form is used to declare an injured workers’ incapacity when the injured worker does not reside in Western Australia.

Noise induced hearing loss

• Noise Induced Hearing Loss Information Sheet (PDF – 595kb)
• 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 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.

WorkCover WA provides an online lodgement facility for submitting applications for conciliation and arbitration.

Most conciliation processes can be managed using the online system. If you are an unrepresented worker or an uninsured employer, you can choose not to lodge your application online and can lodge an Application for Conciliation (Form 100). In certain other limited circumstances, such as a system outage, the Director may also authorise an Application for Conciliation (Form 100) being submitted by all applicants or their representatives where applicable.

Conciliation

Forms used in the Workers’ Compensation Conciliation Service are available from the Conciliation rules and forms page.

Arbitration

Forms required for the Workers’ Compensation Arbitration Service are available from the Arbitration rules and forms page.

General forms

Regulated forms, and guides for completing them, are available on the Regulated forms page.