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Section 39 Fast Track ILARS Grant Application Form

INSTRUCTION

Only complete this form for applications for funding for the provision of initial advice to injured workers in relation to s39 of the Workers Compensation Act 1987. This form should only be used if the insurer has notified an injured worker that weekly benefits may terminate between 1 October 2017 and 1 January 2018 pursuant to section 39.

APPLICANT INFORMATION

Worker Details

SOLICITOR DETAILS

RESPONDENT INFORMATION

Employer Details

INSURER DETAILS

DETAILS OF CLAIM

DETAILS OF INJURY - What was the injury and how was it sustained?

Files must be less than 5 MB.
Allowed file types: jpg jpeg rtf pdf doc docx.