To and From Work Application • AMIEU Newcastle, Northern, South Australian & Tasmanian Branch

To and From Work Benefit provides financial assistance to eligible AMIEU financial members who are unable to work due to an injury sustained while travelling directly to or from work.

Before You Apply !

A current medical certificate must be uploaded before this claim can be submitted. If you do not yet have a medical certificate, please return and complete this application once it becomes available.

✅ Medical certificate
✅ Contact details
✅ Employer details
✅ Details of your accident or injury

MEMBER DETAILS

First Name

Last name

Member No. (If you have it)

Email Address

Phone Number

Street Address

Suburb

Post Code

INCIDENT DETAILS

Date of incident

Time

Where you employed at the time of suffering the incident

No Yes

What Street did the incident occur

What Suburb did the incident occur

Vehicle Registration Number

Full Name of Driver if different from above

Street Address if different from above

Suburb

Post Code

Where were you going?

How did it occur?

Nature and extent of injuries

EMPLOYER DETAILS

Employer/Company Name

Employer Phone Number

Date of medical consultation

Time

Date you last worked

Have you been able to work in any capacity since the accident occured

No Yes

If yes, provide full details

Have you engaged in any other occupation following the incident

No Yes

If yes, provide full details

Details of the Medical Practitioner who attended the incident

Full Name

Address

Please upload your Invoice

I hereby declare that the information provided above is true, accurate, and complete to the best of my knowledge and belief.

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