Compsol Prefund Consent Form Generation Tool

CONSENT FORM GENERATION TOOL

Date

INJURED EMPLOYEE DETAILS:

Employee name and surname:

Employee Identifier Type:

ID Number

Passport Number

Employee ID number:

Date of Accident/Diagnosis:

EMPLOYER (COMPANY) DETAILS:

Company Name:

Company’s Compensation Fund Registration number:

Physical Address:

Contact person:

Authorised person (undersigned):

Contact number:

Email Address:

I, being duly authorized by the Employer of the above Injured Employee, hereby give consent to Compensation Solutions (Pty) Ltd to register the injury-on-duty / Occupational Disease claim on behalf of the Employer on the Compensation Fund’s online claim’s management system or alternatively at the relevant Department of Labour. We also confirm that in order to complete the registration of the claim, the following required documents were made available:

Employer’s report of an occupational accident/disease duly completed (W.Cl. 1 or W.Cl. 2);
Copy of the employee’s ID / Passport
First Medical Report of completed by First treating Doctor (W.Cl. 4 or W.Cl. 22)

We confirm that the details of the employer and employee are accurate and correct.

Yours Faithfully

Difficulty signing? leave this field blank

Duly Authorised Signature

Reset Signature Add Signature

Save Progress

Generate Consent Form

INJURED EMPLOYEE DETAILS:

EMPLOYER (COMPANY) DETAILS:

Email Consent Form

Sign Consent Form

Error

Warning

Generate Consent Form

Download Consent Form