Get Work Cover Form 100

The Work Cover Form 100 is a crucial document for initiating a conciliation application related to workplace injuries. This guide provides straightforward instructions for completing the form online, ensuring a seamless submission process.

Follow the steps to fill out the Work Cover Form 100 online effectively.

1. Click the ‘Get Form’ button to access the Work Cover Form 100 and open it in your online form editor.
2. Begin by entering your name in Section A, identifying yourself as the applicant. This section requires the full name of the individual making the application.
3. In Section B, fill out the respondent's name, which refers to the employer or entity against whom the application is filed. If there are multiple respondents, indicate that a Form 105 should be completed.
4. Complete Section C by selecting the appropriate box to indicate who is lodging the application, whether it is the worker, an employer representative, or another designated individual.
5. Sign and date Section D to confirm your readiness to proceed with the dispute. It is essential that this section is signed; otherwise, the form will be rejected.
6. Provide injury details in Section E, including the date of injury, the date the claim was made, the claim number, and a brief description of the injury.
7. Fill out Section F with the worker's personal details, including title, given names, surname, occupation, date of birth, and contact information such as phone numbers and email.
8. If applicable, enter details for the worker’s representative in Section G. This includes the company's name, a contact person, and their communication details.
9. Complete Section H with the employer's information, including the employer’s name and contact information for correspondence.
10. Provide additional details in Sections I and J for the employer’s and insurer's representatives, as applicable.
11. If there are any other parties involved in the dispute, fill out Sections L and M to include their details.
12. In Section N, outline each matter in dispute clearly to convey the nature of the issue.
13. Indicate the desired outcomes in Section O based on the dispute’s details.
14. Section P requires you to outline any attempts made to resolve the dispute before submitting this application.
15. finally, gather and list any supporting documents you are submitting with your application in Section Q.
16. After reviewing all entries to ensure accuracy, save your changes and proceed to download, print, or share your completed Work Cover Form 100.

Complete your Work Cover Form 100 online to initiate your conciliation application today.