Total Permanent Disability Assessment Referral Submit an enquiry for a Total Permanent Disablement Assessment Simply fill out the form below. You will be able to upload any relevant documentation before submitting the enquiry. Step 1 of 5 20% Referrer DetailsName* First Last Title* Address* Street Address City State / Province / Region ZIP / Postal Code Is your postal address different to the above? Yes Postal Address Street Address City State / Province / Region ZIP / Postal Code Phone*FaxEmail* Claimant DetailsName* First Last Date of Birth*DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Claimant Address* Street Address City State / Province / Region ZIP / Postal Code PhoneMobile*Language* English Occupation* Date of Injury*DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Nature of Injury*Claim Number* Reference Number* Claim DetailsBenefit Amount (This can be left blank) Policy Definition* Relevant date of Assessment* Current Day Specify Date Date* DD slash MM slash YYYY Insured's location* Relevant Background Assessment Format* Face to Face Assessment Paper based assessment Telephone interview Please provide information regarding the Insured's education training and experience with the referral*Cost Approved* Documentation Drop files here or Select files Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB. Additional Information Service RequirementsAn Employability Assessment identifies suitable employmemnt options that the Insured is suited to, based on his / her education training and experience and medical work capacity. Please supply medical information which documents the Insured's medical capacity to work with this referral) Employability Assessment (EA) An Employability Assessment identifies suitable employmemnt options that the Insured is suited to, based on his / her education training and experience and medical work capacity. Please supply medical information which documents the Insured's medical capacity to work with this referral)Please include the following information in the report Transferable Skills Assessment Job Match Report Labour Market Research A Transferable Skills Assessment identifies suitable employment options that the Insured is suited to, based on his / her education training and experience. The report does not comment on the medical suitability of each option but may be sent to a medical practitioner to comment on. Transferable Skills Assessment A Transferable Skills Assessment identifies suitable employment options that the Insured is suited to, based on his / her education training and experience. The report does not comment on the medical suitability of each option but may be sent to a medical practitioner to comment on.Please include the following information in the report Transferable Skills Assessment Job Description Labour Market Research Other Please provide a description of the service required*Please provide a description of the service requiredDocumentationFile upload Drop files here or Select files Max. file size: 50 MB. Please upload any documentation to support your referral (to a maximumm of 8MB total). Δ