A form for injured workers to nominate a superannuation fund.
Important: Please download this PDF to your computer. You can fill it in using Adobe Reader but it will not save if you attempt to fill it in using your web browser.
Fill in this form so your authorised agent can start making superannuation payments into your fund.
You will need to fill in parts 1, 2, 3 and 5, or if nominating a self-managed super fund - parts 1, 2, 4 and 5.
Ensure you sign the consent and declaration. You can digitally sign using an Adobe ID or by inserting a photograph of your signature. Use the 'Fill and sign' function in Adobe Reader to do this.
Return the completed form to your WorkSafe agent.