Request workers compensation claims information on behalf of someone else

This form is to request workers compensation claims information on behalf of someone else. Use this form if you are a lawyer or other person acting for or representing a worker.

All fields are required unless otherwise indicated

Your details

Title

Surname

Given names

Position title (if legal practitioner)

Company name (if legal practitioner)

Company address (if legal practitioner)

Residential address (if not a legal practitioner)

Suburb/Town

Post code

Postal address (if different to above)

Phone number (if email not available)

Upload your proof of identity document This is required unless the request is being made by a legal practitioner on behalf of someone else

Worker's details

Worker's full name

Date of birth (dd-mm-yyyy)

Details of the claim

Date injury happened

Place where injury happened

Nature of injury (e.g. fractured leg)

Employer at time of the injury

Employer’s insurer (if known)

I want to have the fee waived because

I am a Member of Parliament requesting the information in relation to official business
I am experiencing financial hardship (a proof supporting your claim is required)
I am requesting information in order to use it for general public interest or benefit (a proof supporting your claim is required)

Upload proof supporting your claim in order for the fee to be waived (for example, a copy of your concession card if you are claiming financial hardship) in PNG, JPEG or PDF format, no larger than 5 MB in size

Upload proof supporting your claim in order for the fee to be waived (for example, a document saying how you will use the information you are requesting for general public interest or benefit) in PNG, JPEG or PDF format, no larger than 5 MB in size

Request workers compensation claims information on behalf of someone else

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