Title of Document Here

Partial incapacity form
For employers to complete

Online at www.workcoverqld.com.au

Please complete and return to WorkCover Queensland at the end of each week By phone on 1300 362 128

By fax to 1300 651 387

  Claimant details
Name / Claim number
Date / Usual Hours Worked / Actual hours worked / Leave Hours Taken / Is leave claim related? Y/N / Allowances – Type & Amount
Monday // / : / : / :
Tuesday // / : / : / :
Wednesday // / : / : / :
Thursday // / : / : / :
Friday // / : / : / :
Saturday // / : / : / :
Sunday // / : / : / :
Total / : / : / :

WorkCover will deduct relevant allowances not included in NWE Calculations prior to processing top up wages

Hourly rate of pay $ /hour / Gross wages paid for period $
(based on actual hours worked) / Total Allowances paid for period $ / Reimbursement to (please tick)
Worker
Employer
  Progress to date
  Declaration
The information I have provided is true and not misleading.
Name / Organisation/Company
Phone number / Signed / Date

Please note: The claimant may experience tax implications when participating in Suitable Duties (Partial Hours) as a result of being paid by more than one party.

ABN 40 577 162 756 Page 1 of 1
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