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Electronic funds transfer application form - worker

Contact details
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.

Bank account details

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.