Victorian WorkCover Cover Note Request

All questions marked with an asterisk (*) are required.

Employer Details
Legal Name of Employer (Company name or full names of incumbent/s if applicable): *
Address (Line 1) *
Address (Line 2)
Suburb *
State *
Post Code *
Date employer commenced to pay remuneration: *
No. of Workplaces: *
Contact Name: *
Contact Position: *
Email Address:
Phone No.: *
Fax No.:

The Cover Note is effective for 30 calendar days from the date of your request. We require a completed Application for a WorkCover Policy form to be submitted to us prior to expiry of Cover Note.
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