What is the W.Cl.3 form used for?

The W.Cl.3 is the official Notice of Accident and Claim for Compensation under the Compensation for Occupational Injuries and Diseases Act (COIDA), 1993. It is completed by or on behalf of an injured employee, or their dependants if the employee died, to claim compensation from the Compensation Commissioner for a workplace accident.

Who completes the W.Cl.3, the employer or the employee?

The W.Cl.3 is completed by or on behalf of the injured employee. Where the accident caused the employee's death, it is completed by the dependants claiming compensation. This is different from the W.Cl.2, which is the employer's report of the accident.

What is the difference between the W.Cl.2 and the W.Cl.3?

The W.Cl.2 is the employer's report of a workplace accident to the Compensation Commissioner. The W.Cl.3 is the employee-side notice of accident and claim for compensation. Both relate to the same accident, and a complete claim usually needs both documents on file.

Where do I send the completed W.Cl.3?

Send the completed W.Cl.3 to the Compensation Commissioner, P.O. Box 955, Pretoria, 0001. This submission address is printed on the form itself.

What documents must I attach to the W.Cl.3?

Attach a First Medical Report (W.Cl.4) from the treating doctor, proof of the employee's earnings at the time of the accident (a payslip showing cash, allowances and bonuses), and, where the accident caused death, the details of every dependant claiming compensation.

What information about the accident do I need?

You need the date, time and place of the accident, a description of what the employee was doing and how the accident happened, the nature and extent of the injury, and the name and address of anyone who saw the accident.

Why does the form ask for earnings per week and per month?

The employee's earnings at the time of the accident determine the compensation amount. The form lets you record gross cash earnings, regular allowances, bonuses, and the cash value of quarters or food per week, per month, or both. Enter the amounts as they actually applied.

What must I fill in the dependants section?

Only complete the dependants table if the accident resulted in the death of the employee. List every dependant claiming compensation with their full name, address, date of birth and relationship to the employee. For all other accidents, complete the next-of-kin table instead.

Do I need to write in block letters?

Yes. The W.Cl.3 must be completed in BLOCK LETTERS. FillMeIn formats your entries for the form automatically so the details stay legible for the Compensation Fund.

Is my information kept private when I fill the W.Cl.3 online?

Yes. FillMeIn processes all data entirely on your device. Employee identity numbers, earnings details, dependant information and every other entry never leave your phone or computer. Nothing is sent to our servers or stored in the cloud.

W.Cl.3: Notice of Accident and Claim for Compensation

Department of Employment and Labour

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