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Workers' Compensation Dust Diseases Board of NSW
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Worker's Compensation Dust Diseases Board of NSW
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Forms

The compensation application forms listed below are available in both PDF and Interactive PDF formats.  Interactive pdfs allow you to complete the form on your computer.  Alternatively please call the Dust Diseases Board on (02) 8223 6600 and we will be happy to send you a form in the post.

Compensation Application Forms

 Application Form  Description Forms
 Application by past or present worker for workers' compensation benefit

This form is used by a person who has been medically examined and has or is suspected to have a compensable dust disease to apply for workers' compensation benefits.

            

pdf

interactive pdf 

   

 Request by part or present worker for a medical examination

This form is used by a person who has been exposed to hazardous dust while employed as a NSW worker and who is seeking medical assessment to determine if the person has a compensable dust disease.

pdf

 

interactive pdf

 

 Application by dependant/s of a deceased worker for compensation This form is used by the dependants of a worker to apply for compensation for themselves following the worker's death. If the worker was receiving benefits from the DDB durinh his/her lifetime, only this form is required.  If the worker was not receiving benefits from the DDB, the dependent person will aslo need to complete the following supplemenary application from.

 

pdf

 

interactive pdf

 

Supplementary Application by dependant of deceased worker for workers' compensation benefit Dependants of a deceased work who WAS NOT receiving benefits from the DDB during his or her lifetime, must complete both the Application form listed above and this supplementary form. 

 

pdf

 

interactive pdf

 

 

Other Related Forms

Authority to Release Medical Records This form is used to give authority to the DDB to obtain your medical  records pdf
Medical Authority Form - Next of Kin This form is used by the family of a worker to give authority to the DDB to obtain a worker's medical records.  This form is used following the death of the work or is the worker is incapable of signing the form. pdf
Statutory Declaration - Proof of Identity This form is used when you are unable to produce documents proving your identity pdf
Statutory Declaration - Proof of defacto relationship This form is used to prove that you are in a defacto relationship pdf

Other Forms             

Proof of Identity Fact Sheet

Change of Address/Telephone Notification

Form of Special Endorsement

Government Information (Public Access) Act 2009:  Application Form

Privacy Disclosure Statement

 

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