The WorkCover conciliation form

Workcover conciliation form

The WorkCover conciliation form – also known as the Application for conciliation form – is the form used to initiate a conciliation.

If you want to contest a decision made by the WorkCover insurer, other than requesting the insurer perform a review of the decision, your first step is to initiate a conciliation with the Workplace injury commission (formally known as the Accident Compensation Conciliation Service).

This page will explore the form in further detail.

Blank copy of the WorkCover conciliation form

Here’s a blank copy of the WorkCover conciliation form if you require it.

You can also get a copy from the Workplace Injury Commission website.

Request for conciliation form – old and new versions

Under the Accident Compensation Conciliation Service, the form was called a request for conciliation form and it used to look like this (below):

ACCS request for conciliation form

Here’s how the form now looks (below).

Workcover conciliation form 1

In order to initiate a conciliation, you should use the new version of the form.

Here’s how to complete the application for Conciliation form:

Section 1: worker details

Workcover conciliation form section 1

This section just requires you to fill in your contact information.

You should indicate whether you want correspondence sent to you relating to the conciliation from the Workplace Injury Commission via email or in the post.

If you need an interpreter because of language difficulties then you should ensure to indicate this.

Likewise if you need special assistance at the Conciliation due to a disability you should indicate this also.

Section 2: assistant, representative and conference details

Workcover conciliation form section 2

In this section you will need to indicate whether you want the conference to be conducted in person, via video or over the phone.

Most conciliations are held by video or over the phone.

If you select an option and lodge the form, you can change how the conciliation is to be conducted down the track. You’re not locked into your choice.

If you have a representative that is assisting you with the conciliation, you should consider how they might want the conference to be conducted.

However at the end of the day, it’s your conciliation so choose the option that suits you best.

This section also asks whether you would like assistance at the conciliation.

If you have already organised representation, such as with a lawyer or a another person, then you can specify that in this section.

If you have not organised representation already, then (if you want representation) you can select WorkCover assist or union assist.

Again, you are able to change this selection down the track after the form has been lodged. You’re able to change your representative, or even choose to represent yourself.

Section 3: dispute details

Workcover conciliation form section 3

You should list your claim number and the name of the insurer as well as the employer to which the WorkCover claim relates.

You should indicate in this section what the dispute relates to.

In this section you should provide more information about the dispute.

You can attach an additional page (or pages) if more space is needed but you really do not need to go into too much detail about the dispute at this point.

For example, if the dispute relates to the termination of your weekly payments you can simply write “termination of weekly payments” and in addition of this you can include with the conciliation form a copy of the notice from the WorkCover insurer in which they advise you that your payments are to be terminated.

Likewise if the insurer has terminated your entitlement to a particular type of medical treatment you could just write “termination of (insert medical treatment here).”

In this section you need to provide reasons for late lodgement, if relevant. The Workplace Injury Commission considers late lodgement to be any conciliation request lodged more than 60 days since the date of the decision made by the WorkCover insurer.

He are a couple of examples of reasons you might write on the form when it comes to late lodgement:

  • If you were trying to get the WorkCover insurer to pay for a particular type of medical treatment and you held off lodging a Conciliation because of this.
  • You were unaware of the need to lodge a request for Conciliation within 60 days from the date the insurer made the decision.

Note that in most cases the Workplace Injury Commission will not prevent you from pursuing a conciliation if you lodge a request for Conciliation outside the 60 days.

Section 4: checklist

Workcover conciliation form section 4

In this section is a checklist which you should go through and tick what is relevant to the particular dispute.

Section 5: declaration and submission

Workcover conciliation form section 5

This is the declaration and submission section where you will need to sign and date.

Note that if you have a representative such as a lawyer they are able to lodge this form on your behalf.

They can complete and lodge the form without you having to sign the form.

Your representative will need to tick they have authorisation to lodge the form on your behalf, as well as authorisation to communicate with the Workplace Injury Commission in relation to the application.

There is a privacy collection statement below this which you should read.

How do I lodge the conciliation form?

To lodge the form you should email AFC @ or mail it to GPO box 251 Melbourne 3001.

Once the form has been lodged you should receive an acknowledgement from the Workplace Injury Commission within a few days and they will let you know if there are any issues with processing the application (eg: you haven’t provided enough information relating to the WorkCover dispute)

You can expect a conciliation in most cases to be scheduled within the about four to six weeks after the form has been submitted to the Workplace Injury Commission.

Again, if you missed it above, here’s a blank copy of the conciliation form that you can use.

You can obtain a copy of the form from the Workplace Injury Commission’s website.


The Application for conciliation form, previously called the request for conciliation form, is the specific form that you will need to fill out if you want to initiate a WorkCover conciliation.

The form is made up of 5 different sections.

If you have a representative such as a lawyer, they are able to complete and lodge the form on your behalf without the need for you to sign it.

Once the form has been lodged with the Workplace Injury Commission, you can generally expect a conciliation to be scheduled within the following four to six weeks.

Please keep in mind that the information contained on this page should not be considered legal advice and no content on this site should replace the need to obtain advice tailored to the specific facts of your case. The facts of a case can significantly alter the advice that can provided. This site only provides general advice. Read more here.

To contact Michael or Peter call 1800 746 442 or email [email protected].

Written by the Work Injury Site team