EFT Application Form

Contact details

Surname

Given name/s

Claim number

Postal address

Postcode

Phone number

Email address

Collection of personal information

Personal information collected in this form by Gallagher Bassett Services P/L is used for the purposes of processing claim payments and injured worker reimbursements. Gallagher Bassett will not disclose this information to any other organisation or third party without your written consent.

If you have any further questions regarding your WorkCover claim, please do not hesitate to contact your case manager.

Signature of applicant

Name of applicant

Bank account details

Name of bank or financial institution

Suburb/town of bank or financial institution

Name of account (the exact name(s) the account is held in)

Bank/state/branch no. (BSB) or financial institution number

Account number

Signature of account holder 1

Signature of account holder 2

If a joint account both signatories must sign. If a company or trust account two directors must sign.

This request to deposit funds directly into the account described in the schedule above is valid until further notice. If at any time the account details change for any reason then formal notification in writing will be required. WorkSafe Victoria will under no circumstances accept a change in the bank or financial institution details without a signed written request.

Electronic funds transfer application form - worker

Contact details

Collection of personal information

Bank account details