Premium review application form

Use this form to request a review of a premium, premium penalty, estimated future cost of a claim or acceptance of liability for a claim in certain circumstances.

Shape
 
Published: 14 Oct 2022
 
File type: PDF
 
File size: 529.91 kB
 
Length: 4 pages
 
Reading level: Easy

What it contains

Blank form to complete information.

  • Do not use this form to update the details of your registration such as changes in rateable remuneration, workplace address details, adding a new workplace or anything administrative in relation to your WorkCover Insurance. For these matters, please contact your WorkSafe Agent for assistance.
  • Applicants need to be aware that it is an offence to give false or misleading information in complying with the Workplace Injury Rehabilitation and Compensation Act 2013.
  • If you do not provide the required supporting documentation or complete all questions, your application may be declined or delayed.