Injured Worker / Motor Vehicle

Accident Referral

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 Details

Return to work status (please tick)

Pre-Injury dutiesAlternative/modified dutiesUnfit for work

Currently Working (please tick)

YesNo

Referral Request

Return to WorkFunctional capacity (FCE)Worksite AxSuitable employment AxFit for work AxErgonomic AxExercise PhysiologyPhysiotherapy Pre-employment functional

Attachment/Requirements

Work capacity certificateReferral letterOther

Please upload any workcover related documents

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

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