Print Template - Worker Assist Tasmania

First Name*

Last Name*

Phone*

Email*

Date of birth*

Preferred time to call*

Priority Call**

Morning

Afternoon

**To help us better assist, please fill in the additional fields to fast-track your call back.

Your location

City/Suburb

Gender

Male

Female

Other

Country of Birth

Country

Do you Identify as aboriginal or Torres Strait Islander

Yes

No

Are you a Union Member?

Yes

No

Union Name

Have you lodged a Worker's Compensation claim in Tasmania?

Yes

No

Attached your claim

Accepted file types: pdf, doc, docx, txt, jpg, png, Max. file size: 10 MB.

Date of injury

Insurer name

General Practitioner name

Details of your enquiry/issue

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Name

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Contact Form (Full)