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. Worker's Title MrMrsMsMiss Worker's Surname * Worker's First Name * Date of Birth Mobile Number Home Number Workers Email Your email * Claim Number Insurer Insurer contact Insurer's Email Date of injury Injury Type Occupation Workers Address Street Address Address Line 2 City State Post Code Referral Sources Treating Medical PractitionerEmployerInsurerWorkerOther Referral Source Other Referral Type Vocational Rehabilitation / Initial Needs AssessmentJob AnalysisManual Handling / Work Technique AdviceWork Site AssessmentVocational AssessmentTransferable Skills AuditLabour Market Research (LMR)Other Referral Type Other Status of Worker Working / Full CapacityWorking / Partial CapacityNot Working / Full CapacityNot Working / Partial CapacityNot Working / No Capacity Referrer Details Referrers Name Company Name Telephone Number Address Street Address Address Line 2 City State Post Code Employer Details Company Name Contact Name Telephone Number Employer's Email Address Street Address Address Line 2 City State Post Code Treating medical practitioner details Practice Name Dr's Name Telephone Medical Practitioner's email Address Street Address Address Line 2 City State Post Code Additional Information / Comments / Instructions If you need upload any documents, please use the section below. Please note attachment size limit is 10MB.