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Application for an independent review of an agent decision (PDF version)

You can use this form to apply for an independent review of an agent decision.


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Published: 13 Oct 2026
 
File type: PDF
 
File size: 255.88 kB
 
Length: 6 pages
 
Reading level: Medium

What it contains

The Workers Compensation Independent Review Service (WCIRS)

The Workers Compensation Independent Review Service (WCIRS) is a free, impartial service that reviews certain disputed decisions made by or on behalf of WorkSafe, when a worker believes a decision isn't right and conciliation hasn't resolved it.

An Independent Review Officer (IRO) looks at the available written information and decides whether the original decision was sustainable – that is, whether it has a reasonable prospect of being upheld by a court.

Before you start

Before filling in this form, it will be helpful if you’re familiar with the information contained in our Step-by-step guide to WCIRS.

The step-by-step guide will give you the information you need before applying, including what we can review, how to apply and what to expect from the review process.

Important information about the application and review process is also included in the form itself.

How to apply

There are 2 different ways to apply:

  • The online application form – the quickest way to apply.
  • The PDF application form – download, complete and email or post to us.

Follow the link below if you’d prefer to use the online form to apply.

Independent review of an Agent decision  

Application form for an independent review of an agent decision.

About the PDF form

We will only ask you for information that we need for the review. Although we have access to your compensation claim information, this form will ask you for some of that information to verify your identity and to help us understand which decision you would like reviewed.

Filling in and lodging the PDF form

Once you have filled in this form, you can send it in to us:

  • By email to:
    [email protected]
  • By post to:
    Workers Compensation Independent Review Service
    WorkSafe Victoria
    PO Box 279
    Geelong VIC 3220

Related information

 

FAQs about the Workers Compensation Independent Review Service  

Independent review of an Agent decision  

Application form for an independent review of an agent decision.

Nominating a person or representative for a WCIRS review  

Privacy policy  

WorkSafe Advisory

WorkSafe Advisory is available between 8:00 am and 5:30 pm, Monday to Friday.

1800 136 089 More contact options

Translating and interpreting service

Call 131 450 to translate this information or to speak to WorkSafe in your language.
For more information about this free service, visit Translating and Interpreting Service (TIS National).

For people with hearing or speech loss

An effective way for you to contact us is using the National Relay Service.

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