Workers' compensation claim form
  • 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.

Common law forms
Medical forms
  • 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.
Noise induced hearing loss forms
Dispute resolution forms

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.



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.



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.