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.

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.: