Workers' Compensation and Rehabilitation Amendment Regulations (No. 6) 1999 (WA)

4900 GOVERNMENT GAZETTE, WA [15 October 1999

Workers’ Compensation and Rehabilitation Act 1981

Workers’ Compensation and

Rehabilitation Amendment Regulations

(No. 6) 1999

Made by the Governor in Executive Council.

1.             Citation

These regulations may be cited as the Workers’ Compensation and Rehabilitation Amendment Regulations (No. 6) 1999.

2.             Commencement

These regulations come into operation on the day on which
section 20 of the Workers’ Compensation and Rehabilitation
Amendment Act 1999 comes into operation.

3.             The regulations amended

The amendments in these regulations are to the Workers’
Compensation and Rehabilitation Regulations 1982*.
[* Reprinted as at 14 February 1995.

For amendments to 14 October 1999 see 1998 Index to
Legislation of Western Australia, Table 4, p. 354 and
Gazette of 13 and 16 April, and 22 June 1999.]

4.             Regulation 6 repealed

Regulation 6 of the principal regulations is repealed.

5.             Regulation 6AA amended

Regulation 6AA of the principal regulations is amended after subregulation (2) by inserting the following subregulation —

“

(3) For a claim for compensation by dependants under
section 84I(1)(b) of the Act (in the case of a death), the
information required by Form 2D in Appendix I is
prescribed under section 84I(2) of the Act.

”.

6.             Appendix I amended

(1) Appendix I to the principal regulations is amended by deleting
Form 2A.

15 October 1999] GOVERNMENT GAZETTE, WA 4901

(2) Appendix I to the principal regulations is amended by inserting
after Form 2C the following form —

“

Form 2D

Workers’ Compensation and Rehabilitation Act 1981

Workers’ Compensation Claim Form for Dependants of Deceased Workers

[r. 6AA] to help you. If the deceased had no dependants this form can be used to claim for statutory allowances only (e.g. funeral expenses). Please complete all questions except for the details requested on dependants (see below).

Applicant’s Details

Full Name of Applicant	Surname	Other Names
Occupation	Relationship to deceased worker
i.e. Executor, Wife/defacto, Son, Daughter
Residential Address
Postcode	Telephone No.

Deceased Worker’s Details

Full Name of deceased	Surname	Other Names
worker

Sex	Male	Female	Date of Birth	/ /
Worker’s Occupation
Period of Employment
Residential Address immediately prior to death
Employer’s Details
Full Name of Employer, including trading name
Address of worker’s usual workplace or base

Postcode Telephone No.

Major activity of workplace
(e.g. footwear manufacturing,

sheep farming)

Deceased Worker’s Dependant/s Details

Do not complete the following question if you are claiming for statutory allowances only. Give full details of deceased worker’s dependants as at the date of death:

Name of Date of Residential Occupation Relationship to Dependency

Dependant Birth Address deceased worker Wholly Part
ä Tick Box

4902 GOVERNMENT GAZETTE, WA [15 October 1999

Details of Fatality

Was the death the result of a	Yes	No
work-related injury and/or disease? What was the cause of death?
What were the main tasks/duties of the deceased’s employment when he/she suffered the injury and/or contracted the disease?

In the case of personal Day of the week Time Date

injury, when did it occur? / /

Date of death if different.	Date	/ /
Where did the injury occur? (e.g. Workshop floor, Hay Street, Cloverdale)

In the case of a disease,	Date	/ /	Date of	Date	/ /
what was the date of death?	diagnosis
If known, when was the	Date	/ /	Don’t
deceased first incapacitated	know
by the disease?

Prior to this application,	Have you attached
have any workers’	a copy of any
compensation payments	official notice of

YES NO YES NO

been received or applied for	the deceased’s
in respect of the deceased	death?
(i.e. weekly payments, medical expenses, lump sums).

If yes, please attach as much information as you can

Declaration

I, the undersigned, do hereby warrant the truth of the foregoing statements. I hereby authorize any medical practitioner to disclose to the deceased worker’s employer or his/her insurer and WorkCover WA any information regarding the deceased worker’s medical history.

Signature	Date	/ /
Signature	Date	/ /
INSURER/SELF-INSURER DETAILS

Insurer/self-insurer to complete then detach and forward the duplicate of this notice to WorkCover WA,

2 Bedbrook Place, Shenton Park, WA 6008:

Name of insurer/self-insurer:	Date stamp of insurer/self-insurer
Policy number: Claim number:
WCN:
Occurrence Details Mechanism: Agency: Nature: Body Locn:

”.

By Command of the Governor,

M. C. WAUCHOPE, Clerk of the Executive Council.