Notify WorkSafe Call 1300 366 322
Notify WorkSafe Call 1300 366 322

Completing the Irrevocable Power of Attorney

An Irrevocable Power of Attorney is required once the WorkCover Tasmania Board has granted you provisional approval of your permit.

It enables the Board to access funds under the Excess of Loss policy should you become insolvent while holding your self-insurer permit.

How to complete the Irrevocable Power of Attorney

Use the Irrevocable Power of Attorney form (DOC, 89.0 KB)

Front cover

Insert the date after ‘Dated’.

Insert the full legal name above ‘Grantor’.

Page 1

Complete the Grantor details.

Page 3

Insert the date after ‘Dated’.

Insert the legal name below ‘Executed’.

Have the Director and Secretary sign the signature block.

Have the witness sign the signature block. Insert the details of the witness.

Page 4 (Schedule)

Insert the Full Legal Name and ACN at ‘A’.

Submit to

The Secretary
WorkCover Tasmania
PO Box 56
Rosny Park TAS 7018

Updated: 10th December 2019