Forms

Establishing a policy with GB

New South Wales

Request for new policy    Insurance Proposal        Alternatively apply directly online.

Victoria

Covernote Request Form      WorkCover Application Form     Alternatively apply directly online.

Transfer Existing Policy from another Agent  

Lodging a claim

New South Wales

Initial Notification of Injury:       Online Form version     Hardcopy version

Workers' Compensation Claim Form      Employer's Report of Injury Form    Journey Claim Form

Victoria

In Victoria, it is a legal requirement to submit and utilise hardcopy versions of the claim forms. Please ensure that you keep a copy of the claim form and send the original into Gallagher Bassett.

Worker Injury Claim Form     Employer Injury Claim Form

Valid Worker Claim Form     Valid Employer Claim Form     Valid Medical Certificate

Other forms

New South Wales

• Register of Injuries
• Request for a certificate of currency
• Request for a Declaration of Estimated Wages
• Request for a Declaration of Actual Wages
• Premium Forms Definitions
• Section 36 and 37 (Total Incapacity) - Payment Advice Form
• Section 40 (Partial Incapacity) - Payment Advice Form
• Publications available from WorkCover NSW

Victoria

• Injured Worker Pack
• Employer Information Pack
• Additional Workplace for Existing Policy
• WorkCover Reconciliation Request Form
• WorkCover Compensation Reimbursement Request Form
• Early Notification Flyer
• Register of Injuries   Employers can download a template to set up their own Register of Injury booklets, required in all workplaces. Also download the instructions that should accompany the template.
• Publications available from the WorkSafe Victoria
• Advice of Payments