SUBMIT A REFERRAL


1

Submit Online Form below

Simply Fill in Details below & Submit

3

Call us on 1300 782 183

Simply have all your details handy

 

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STEP ONE: Details of injury and injured party

Claimant / Injured Party Details

Injury Details

Medical Certificate Avaialble?

Insurer/Agent Details (if applicable)

Requirement/s (choose all applicable)

STEP TWO: Details of Employer and Doctor

Employer Details

Other Employer Details - eg line manager

Doctor Details


STEP THREE: Other Details and Attachments

Additional Attachments

Please attach only Word and PDF files of 2MB or less

Additional Comments

Referrer Details

Insurer Approval??


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