Application for Conciliation

Application for Conciliation

Please find attached PDF of your completed Application for Conciliation form.
If you have given us permission to contact you, please expect a call from one of our staff within the next 24 business hours.

Shoud you wish to contact Arnold Dallas McPherson Lawyers, please call us on 1800 242 588 during office hours.

Regards,

— Team

Arnold Dallas McPherson
Worker Details

Section 1
Full Name

First NameLast Name
Preferred Name
Date of Birth

DayMonthYear
Gender (optional)
Pronouns (optional)
SHE/HER/HERS - HE/HIM/HIS - THEY/THEM/THEIRS
Email Address
Phone Number(s)
Mobile numbers preferred
Preferred Contact Method

EmailPost
Postal Address
Do you require an interpreter?

YesNo
What language do you speak?
Workplace Injury Commission can arrange a free interpreter including an Auslan interpreter. A support person cannot interpret for you at a conference.
Do you have a second preference?

YesNo
Your second language preference
Do you need special assistance at conciliation due to disability?

Yes (If yes, we will contact you)No

Dispute Details

Section 3
Claim Number(s)
Name of WorkSafe Agent
(or Self-insurer)
Employer Business Name
What does your dispute relate to?

Decision made by the Agent or Self-insurerFailure by the Agent or Self-insurer to respond to a requestFailure by the Agent or Self-insurer to pay weekly paymentsFailure by the Agent or Self-insurer to pay for medical treatmentProvisional paymentsOther
Date of decision

DayMonthYear
Please provide more information about your dispute
If more than 60 days since the date of decision, provide reasons for late lodgement

Checklist

Section 4
To avoid delays with the lodgement of your dispute, please provide supporting documents, if available.

Based on your responses below, if available, you will need to initially provide at least one of the following documents:
Tick all that apply:*

Decision made by the Agent or Self-insurerRequest for treatment if the Agent or Self-insurer has failed to respondCertificates of capacity if the Agent or Self-insurer has failed to pay weekly paymentsInvoice / receipts if the Agent or Self-insurer has failed to pay for medical treatmentOther documents, if applicable (for example, medical reports or payslips)
Decision Made

By the Agent or Self-insurer
Cancelof
Request for Treatment

If the Agent or Self-insurer has failed to respond
Cancelof
Certificates of Capacity

If the Agent or Self-insurer has failed to pay weekly payments
Cancelof
Invoice / Receipts

If the Agent or Self-insurer has failed to pay for medical treatment
Cancelof
Other Documents

If applicable, for example, medical reports or payslips
Cancelof

Declaration and Submission

Section 5
Signature or name of the person lodging this Application for Conciliation

Clear
Date (DD/MM/YYYY)

DayMonthYear
Are are lodging this form on behalf of the worker?

YesNo
If you are, you must have their authorisation and provide your contact information below.
Worker’s Full Name
Worker’s Address
Worker’s Email Address
Worker’s Phone Number
Mobile numbers preferred
Business Name
(If applicable)
I have the worker’s authorisation to:*

lodge this form on their behalf; andcommunicate with the Workplace Injury Commission in relation to the application.
Collection Statement

Workplace Injury Commission (WIC) is the trading name of Accident Compensation Conciliation Service (ACCS), which is a statutory authority established under the current workers compensation legislation. WIC collects personal and health information for the purposes of processing applications for conciliation or referrals for arbitration, and other purposes related to the provision of conciliation and arbitration services, including for its administrative purposes and to evaluate its services. WIC may use and disclose personal and health information, and any documents provided to it, to any party, their representative or to any other person a party has nominated to assist them; to courts and tribunals; to any person or organisation authorised by the party or by law to obtain it; and to WIC’s third-party contractors. WIC is subject to secrecy provisions under the current workers compensation legislation, and only discloses information in accordance with that legislation. A person may be required to provide information to WIC under workers compensation legislation. If they do not provide it, it may impact the progression of conciliation or arbitration. A person may access their personal and health information by contacting WIC directly (contact details are at the top of this form For more information about how WIC manages personal and health data, please refer to our Privacy Policy.
Would you like to lodge your ‘Application for Conciliation’ straight to Workplace Injury Commission?

Yes, lodge this completed ‘Application for Conciliation’ with Workplace Injury CommissionNo, email me this completed copy of my ‘Application for Conciliation’ form
Would you like Arnold Dallas McPherson Lawyers to contact you about your 'Application for Conciliation' matter?

Yes (If yes, we will contact you)No
Should be Empty:

Application for Conciliation

Worker Details

Assistant, Representative and Conference Details

Dispute Details

Checklist

Declaration and Submission