General Information

Worker Name

Date of Birth

Address

Contact Number

Email

Claim Details

Claim Number

Date of Injury

Claims Agent

Case Manager Name(If Applicable)

Employer Name

Return to work status (please tick)

Pre-Injury dutiesAlternative/modified dutiesUnfit for work

Currently Working (please tick)

YesNo

Please upload any workcover related documents

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Referral lead contact details (Doctor, Physio, Occupational Therapist)

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