Employer report form

Employers Mutual may request an Employer Report Form if the claim will be ongoing after 13 weeks and additional information is required.

Submit the form

Complete the PDF Employer Report Form. You must print your application before exiting the document as your information will not be saved.

Printing of the form will produce two (2) copies - keep one copy for your company records, and send the second signed copy through to Employers Mutual either by post to: GPO Box 2575, 5001 or facsimile on (08) 8127 1200. Please be aware that this form cannot be emailed through to Employers Mutual.

Use the Print Form button on the Acrobat document message bar to produce 3 copies of the formUse the Print Form button on the Acrobat document message bar.

Do not use the print button on the browser toolbar
Do not use the Print button on the Acrobat toolbar

Do not use the browser or Acrobat Reader toolbar Print buttons, as they will not produce 3 copies of the form.  

This form is not required to be printed in colour. You can authorise another person to complete this online form on your behalf.