Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. In the first section, 'Send To', enter the name of the contact organization and individual responsible for receiving the claim. Also, include the date using the DD/MM/YYYY format, fax number, and the total number of pages you are submitting.
3. Fill in the 'Worker Details' section with the worker's first name, surname, postal address, suburb, date of birth, state, postcode, claim number, and their telephone number.
4. Provide your 'Employer Details' by entering your organization name, postal address, suburb, contact person's name, position, telephone number, email, fax number, and mobile number.
5. In the 'Claim Details' section, list the name of the pre-injury employer along with their telephone number, fax number, and email contact.
6. Complete the 'Employment Details' section by entering the position title and the commencement date in DD/MM/YYYY format.
7. For 'Payment Details', specify the incremental period you are claiming and the applicable payment amounts. Calculate the total gross wages paid to the worker during the incentive period and indicate the number of weeks and weekly wage. Answer whether the calculated weekly wage is less than the incentive for the period claimed and follow the appropriate subsidy calculation process.
8. In the 'Payee Details' section, provide the payee's name, ABN (if applicable), address, suburb, state, BSB number, account name, bank name, and account number.
9. Complete the 'Declaration' section by securing the required signatures of both the worker and the employer, along with their respective dates using DD/MM/YYYY format.
10. Finalize the form by ensuring all required signatures are obtained and attach necessary documents such as the JobCover placement program agreement and evidence of wage payments before submitting.
11. Submit the completed form to the designated scheme agent or WorkCover for reimbursement, depending on the insurer type.

Start completing your documents online today for a smooth claim process.