Step 1 of 5
Please complete all questions in the following Medical Questionnaire. For any question that you answer “YES” please provide details.
Section (79) of the Western Australian Workers Compensation and Injury Management Act 1981 requires you to disclose any prior illness or injury otherwise you may not be entitled to compensation in the event of illness or injury.
“Wilful and false representation
Where it is proved that the worker has, at the time of seeking or entering employment in respect of which he claims compensation for an injury , wilfully and falsely represented himself as not having previously suffered from the injury an arbitrator may in the arbitrators discretion refuse to award compensation with otherwise would be payable”
[Section 79 amended by No. 48 of 1993 s. 28(1); No. 42 of 2004s. 63, 146 and 147.]
Physical abilities: Do you have, or have you ever had difficulty with any of the following:
Please read the extract from the Workers’ Compensation and Rehabilitation Act 1981 Section (79) prior to completing this Workers Compensation declaration:
“Where it is proved that the worker has, at the time of seeking or entering employment in respect of which he claims compensation for a disability, wilfully and falsely represented himself as not having previously suffered from a disability a dispute resolution body may at its direction refuse to award compensation which otherwise would be payable”