Non Workers Compensation Referral Form

Please fill in and submit the form below. For help filling in this form please visit the WorkCover WA website.

Alternatively, you can print out the form and fax or mail it to one of our offices.







Working / Full CapacityWorking / Partial CapacityNot Working / Full CapacityNot Working / Partial CapacityNot Working / No Capacity

Referrer Details





Employer Details





Treating medical practitioner details