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Comcare Registration Form

1. Your details:

First Name*:
Last Name*:
Date of birth:
Sex:
Address:
Daytime telephone No.:
Email*:
Mobile*:

2. Employment:

Name of Employer: Address: Dates of Employment:
From: To:
Employee Number (if relevant):

3. Description of Injury suffered by you:

Place(s) where injury occurred Approximate date(s) when injury occurred: Name(s) of witnesses:

4. Description of injuries:

  • Please provide a written account of the injuries:
(a) Physical Injury:
(b) Psychological Injury:
(c) Incapacity for Work:
  • If you have attended any medical or other practitioner or any hospital for treatment of these injuries, please provide the following information where possible:
Name of Practitioner/hospital: Address: Dates attended:

5. Have you had any previous injuries or workers compensation claims?

If "yes" please give details
Nature of Injury:
Date of Injury:
Employer (if injury was work related):
Have you received compensation or damages for any pre-existing injuries?
If yes, what is the amount of compensation/damages received?

6. If you wish to add anything to the information you have given above, please do so in the space below:

7. Tell us about yourself:

Are you married?
Do you have children?
If yes, how many?
Are you presently employed?
What is your occupation?
Average Gross Annual Earnings?
How did you hear of our office?
Have you previously sought legal advice re your injury? If so, who has acted for you?

captcher

Address:

247 Park Street, South Melbourne, Vic 3205
PO Box 42, South Melbourne,VIC 3205
Phone: (03) 9686 6610

Keep in Touch:

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