W.C.I.F 47
WORKERS’ COMPENSATION INSURANCE FUND
Workers’ Compensation
Police Ref (if known) _______________________________
P. O. Box ________________________________
__________________________________________
__________________________________________
Date: ____________________________________
The Member in Charge,
Z. R. Police
__________________________
__________________________
___________________________
WORKERS COMPENSATION CLAIM NO: _________________________
Your assistance is sought in providing the following information in order that we may establish the validity of a claim made
under the NSSA ACT, Chapter 17.04. authority for the provisions of this information is contained in P.G.H.Q. all stations
letter AS66/79, Dated 30/7/1979 (File 67 Other Governments/Departments/27 Investigation of Crime).
Such information that is available to us has been completed. Should this conflict with your information please advise.
NAME OF INJURED WORKER_______________________________________________________________________
NATIONAL REGISTRATION NUMBER (if available) _____________________________________________________
NAME AND ADDRESS OF EMPLOYER________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
RESIDENTIAL ADDRESS OF WORKER_________________________________________________________________
___________________________________________________________________________________________________
DATE OF INJURY ___________________________________________ TIME_______________________________
NATURE OF INJURY_______________________________________________________________________________
POLICE STATION AT WHICH ACCIDENT WAS REPORTED______________________________________________
NAME OF INVESTIGATING OFFICER (if known)_________________________________________________________
Circumstances surrounding the accident as described by the employer:
PLEASE COMMENT ON THIS INFORMATION OVERLEAF
1
W.C.I.F 47
FOR COMPLETION BY Z. R. POLICE (as applicable):
Please confirm the information overleaf and supply any additional facts which may be relevant.
It is vital for us to establish that the worker was on duty at the time of accident, and that he was about his
employer’s business when he was injured, therefore any facts which may confirm the position will be
appreciated.
Please give brief circumstances describing the incident which will assist the Department to determine the
acceptability of the claim
ARE INJURIES AS STATED OVERLEAF? IF NOT, GIVE DETAILS
TRAFFIC ACCIDENT. T.A.B No.
DATE
TIME
Place of accident and direction in which vehicles were travelling.
VEHICLE “A”
NAME OF DRIVER
VEHICLE “B”
__________________________
_______________________________
__________________________
________________________________
__________________________
________________________________
__________________________
________________________________
__________________________
________________________________
__________________________
________________________________
REGISTRATION NUMBER __________________________
________________________________
VEHICLE OWNER
__________________________
________________________________
INSURANCE COMPANY
__________________________
________________________________
NAME AND ADDRESS OF
EMPLOYER
MAKE OF VEHICLE
IS ANY PROSECUTION INTENDED? PLEASE GIVE DETAILS AND OUTCOME IF KNOWN
DATE STAMP
For Member in Charge, Z. R. Police
L/A 10M.2/82
(Name:
2
No.
)