Worksafe, TAC, or Insurance Membership Request Form

Access & Inclusion is at the forefront of what we offer at the Mill Park Leisure. We are committed to partnering with third parties to enable insurance and rehabilitation memberships.
Your insurance and rehabilitation membership can be used for a variety of activities such as warm water physical therapy, lap swimming, gym work and exercise physiologists (where approved). Speak to your health professional about what therapy you require. We work with many leading agencies including Transport Accident Commission (TAC), Gallagher Bassett, GIO, EML, and Workcover, just to name a few.

To start your journey at the Mill Park Leisure please follow these steps.

If required, download a QUOTE FOR MEMBERSHIP to supply to your provider
Once your provider supplies an APPROVAL FORM with claim or case number, please complete the form below
We will set up your membership and invoice your provider. Please allow 1 - 3 business days for processing.

Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email Address*

example@example.com

Gender*

MaleFemaleNon-BinaryPrefer not to say

Emergency Contact Name*

First NameLast Name

Emergency Contact Number*

Please enter a valid phone number.

Membership Type*

Have you had a Work Cover or Funded Membership before?*

YesNo

Third Party Provider*

If Other, please state the name here*

Case Manager's Name (Required for all Third-Party Applications)*

First NameLast Name

Case Manager's Email Address (Required for all Third-Party Applications)*

example@example.com

Case/Claim Number*

File Upload*