Claim acknowledgement pro-forma
Sample of a letter to formally acknowledge receipt of a completed Workcover - Workers Claim Form
This downloadable document is designed for handwritten acknowledgement of and employees claim form.
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| This letter formally acknowledges receipt of a completed “Workcover – Workers Claim Form” Workers Name: ………………………………………………………………………… Occupation: …………………………………………………………………………….. Date of Birth: …………………………………………………… Supervisors Name: …………………………………………………………………….. I hereby acknowledge receipt of the Workcover Workers Claim Form from; …………………………………………………………workers name. The claim form was received on the …………day of ……….month ……… year. Signed: …………………………….…signature ……………………………… print name Position with Company ………………………………………………………………… Witnessed …………………………………. Workers signature ………………………………………………print name Date ……………………………………………… The above information is true and correct to the best of my knowledge. Signed ……………………………………… Employer Representative. Date ………………………………. |