This form is to be used for applications for grants of funding for the provision of advice to injured workers in relation to section 39 of the Workers Compensation Act 1987.
When to use this form
This form should only be used if the insurer has notified an injured worker that weekly benefits may cease because of the operation of section 39 of the Workers Compensation Act 1987.
Submitting this form
Step 1 - Complete the form
Step 2 - Print the form
Step 3 - Sign and return the consent and declaration section
Step 4 - Return to WIRO by email to firstname.lastname@example.org as a PDF with accompanying documentation.