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Circumstance Enquiry (Agents)

This request for CIRCUMSTANCES investigation requires numerous fields to be completed *. Instructions requested electronically will be confirmed by an automated response from CHS to the requesting email address. Any supporting documentation should be sent to CHS either by normal postal service, or as PDF via email. If you require to view the report as it is compiled via the CHS Secure Access Facility, please ensure that you have a User Name and password. If you do not have a User Name and Password, click here.

Agent Details

Claims Agent *
NOTE: Panel Solicitors are required to use a different form.
Please access here
If Other
Instructing Officer *
Authorising Officer *
Email Address *
Phone
Facsimile
Claim Number *
Liability Status * Accepted Pending Denied
   
Job Number *
Purpose of enquiry
if other detail here >>>
300  characters left.

Worker's Details

Name *
Address *
Suburb/Town P/C
Phone contact *
Date of Birth * (dd/mm/yy)
Date of Injury * (dd/mm/yy)
  If injury occurred over a period of time please specify
Legal Representation * No Yes
Solicitor *
   

Employer Details

Employer *
Workplace location *
Employer contact
Employer phone
   

Additional Information

Date report required
Other information Please detail any other information that may assist the investigation
 
  300  characters left.
   
Please forward a copy of this submission to the following email address:

Supporting documents

Please ensure that any supporting documents are forwarded or faxed to our office

CHS undertakes to obtain all employment records relevant to the worker, including the application for employment, wage records, leave records, all medical certificates of any nature, copy of the Accident Injury Report Book, any safety investigation reports relevant to the alleged incident(s), and all Group Certificates for a period of 3 financial years prior to the incident(s) where possible.


* required field