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
Monday
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Tuesday
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Wednesday
/
Thursday
Friday
/
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/
Saturday
Sunday
/
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/
/
Total
Is leave claim
related? Y/N
Allowances – Type &
Amount
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
Phone number
Organisation/Company
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
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