Willis Temby | Injury Notification Form
Willis Temby's Injury Management Services are provided in partnership with RTC
Business and Policy Details
Business Name
*
Name of Insurer
*
AAI Limited trading as GIO Workers Insurance
Allianz Australia Insurance Limited
Insurance Australia Limited trading as CGU Workers Compensation
QBE Insurance (Australia) Limited
Zurich Australian Insurance Limited
Policy Number
*
Who is your regular contact at Willis Temby?
*
Please Select
Alex Rowland
Andrew Dodd
Brett Piggott
Cameron Gaspar
Emma Caddy
Edward Shand
Fleur Dias
Haidee Moore
Harry Strapp
Jake Clamp
Josh Hall
Lizzy Barron
Madison Tokeley
Mitch Concanen
Oliver King
Rebecca Singleton
Tara Ransted
Unsure / Not Listed
Back
Next
Injured Employee Details
You will be asked for your details as the Employer on the following page.
Name of Injured Employee
*
First Name
Last Name
Contact Number
*
-
Area Code
Phone Number
Contact E-mail
*
Date of Birth
/
Day
/
Month
Year
Residential Address
Street Address
Street Address Line 2
City
State
Post Code
Back
Next
Details of Injury
Date of Injury
*
/
Day
/
Month
Year
Suspected Injury or Medical Diagnosis
*
e.g. fractured arm, jarred neck, etc.
Please provide a brief description of what caused the suspected injury
At the time of this notification, has any treatment been provided?
*
Yes
No
Unsure
At the time of this notification, has the employee been prescribed any medication?
*
Yes
No
Unsure
Do you suspect this to be a Lost Time Injury (LTI)?
*
Yes
No
Unsure
Has the employee indicated that they want to lodge a Workers' Compensation Insurance claim?
*
Yes
No
Unsure
Working Capacity
Please upload a Certificate of Capacity (if already obtained):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Pre-Injury Employment
Position Title
*
Brief Description of Responsibilities and Duties
*
Pre-Injury Working Hours (per Week)
e.g. 38 hours
Employment Type
*
Full Time / Part Time / Casual / Contractor
Tenure of Employment with your Business
*
e.g. 6 months
Additional Information and Documentation
Please provide any additional information or details that you feel are relevant to this Injury Notification:
Please upload any additional documentation that you feel is relevant to this Injury Notification:
Browse Files
Drag and drop files here
Choose a file
This could include incident or witness reports, photographs, medical certificates, etc.
Cancel
of
Back
Next
Your details (the Employer)
Name
*
First Name
Last Name
Position
Contact Number
*
-
Area Code
Phone Number
Contact E-mail
*
I understand and accept that this information will be collected and used in accordance with Willis Temby's Privacy Policy
*
Yes, I understand and accept
Signature
*
Submit
Should be Empty: