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Workers Compensation
 Client No.
TOWER
Claim Form
 Agency No.
Insurance

WORKERS NAME.
POLICY NO.
DUE DATE
CLAIM NO.
ISSUE OF THIS FORM DOES NOT CONSTITUTE AN ADMISSION OF THE COMPANY'S LIABILITY
NAME:       
ADDRESS
PHONE:
BUSINESS
PRIVATE
FACSIMILE

DATE OF INJURY OR DEATH: TIME:

SECTION 1 - TO BE COMPLETED BY THE WORKER:
NAME: ADDRESS:
DATE OF BIRTH: JOB DESCRIPTION:
DATE OF ACCIDENT: PLACE OF ACCIDENT:
WHEN DID YOU STOP WORK:         DATE:      TIME:
WHEN DID YOU RESUME WORK:    DATE:      TIME:
WHAT ARE YOUR INJURIES?
WHAT CAUSED YOUR INJURIES?
ARE YOU MARRIED? FULL NAME OF SPOUSE
DATE OF MARRIAGE PLACE OF MARRIAGE
DOES YOUR SPOUSE LIVE WITH YOU. IF NO WHERE? IS YOUR SPOUSE TOTALLY OR PARTIALLY DEPENDENT ON YOU

PLEASE LIST ALL DEPENDENTS INCLUDING CHILDREN UNDER 16 YEARS OF AGE:
NAME
RELATIONSHIP TO YOU
DATE OF BIRTH
PLACE OF RESIDENCE
IS THE PERSON TOTALLY DEPENDANT UPON YOU. IF NOT, HOW MUCH?

SECTION 2 - TO BE COMPLETED BY EMPLOYER

WAS THE INJURED WORKER DIRECTLY EMPLOYED BY YOU? YES/NO IF NO, STATE DETAILS OF EMPLOYMENT:
AVERAGE WEEKLY EARNINGS (INCLUDING OVERTIME) K
HOURS WORKED PER DAY:
HOURS WORKED PER WEEK: RATE OF PAY PER HOUR:   
HOW LONG HAS THE WORKER BEEN EMPLOYED BY YOU?
WAS THE WORKER ACTUALLY EMPLOYED AT THE TIME OF THE ACCIDENT?                         
WAS THE ACCIDENT REPORTED TO YOU OR THE WORKERS SUPERVISOR AT THE TIME OF OCCURRENCE?
IF NOT WHEN?                    
WHAT WAS THE WORKER DOING AT THE TIME OF THE ACCIDENT? CAUSE OF ACCIDENT?        
NATURE OF INJURIES?
DID THE WORKER CONTINUE WORKING AFTER THE ACCIDENT?
IF NO STATE TIME THE WORKER CEASED WORK:
DATE             TIME:

IN YOUR OPINION WAS THE INJURY DUE TO NEGLIGENCE, DIRECT OR INDIRECT? IF SO STATE BY WHOM AND THE NATURE OF SUCH NEGLIGENCE:

WAS THE INJURY DUE TO THE SERIOUS AND WILFULL MISCONDUCT OF THE WORKER?
WAS THE WORKER SOBER AT THE TIME OF THE ACCIDENT?

ACCORDING TO YOUR RECORDS, WHAT DEPENDANTS DOES THE WORKER HAVE.
NAME
RELATIONSHIP TO WORKER
DATE OF BIRTH
PLACE OF RESIDENCE
DEGREE OF DEPENDENCY


TO BE COMPLETED BY THE EMPLOYER

I/WE DECLARE THAT THE INFORMATION CONTAINED IN THIS CLAIM FORM IS TRUE AND CORRECT TO THE BEST OF OUR/MY KNOWLEDGE.

SIGNATURE OF EMPLOYER DATE

TO BE COMPLETED BY THE INJURED WORKER

I HEREBY AUTHORISE ANY HOSPITAL, DOCTOR, OR OTHER PERSON WHO HAS GIVEN ME MEDICAL ATTENTION, OR MY EMPLOYER TO GIVE TOWER INSURANCE PNG LIMITED OR IT'S REPRESENTATIVES, ANY AND ALL INFORMATION WITH REGARD TO ANY INJJURY OR SICKNESS, MEDICAL HISTORY, OR CONSULTATION I HAVE PREVIOUSLY HAD. I ALSO AUTHORISE THE COMPANY OR IT'S REPRESENTATIVES TO OBTAIN FULL HOSPITAL RECORDS AND EMPLOYER RECORDS AS REQUIRED.

I AGREE THAT A PHOTOSTAT COPY OF THIS AUTHORITY IS AS EFFECTIVE AND VALID AS THIS ORIGINAL.

AND I DECLARE THAT THE INFORMATION SUPPLIED IN THIS CLAIM FORM IS AS TRUE AND ACCURATE STATEMENT IN REGARD TO MY CLAIM FOR COMPENSATION. I AGREE TO ADVISE MY EMPLOYER IF ANY CIRCUMSTANCES IN REGARD TO THIS CLAIM, MY DEPENDANTS OR MY MEDICAL CONDITION SHOULD CHANGE.

SIGNATURE OF WORKER DATE