Western Australian Current Regulations

WORKERS COMPENSATION AND INJURY MANAGEMENT REGULATIONS 2024 - SCHEDULE 5

[r. 138]

Form 1 ‑ Infringement notice

Workers Compensation and Injury Management Act 2023 INFRINGEMENT NOTICE					Infringement notice no.
Alleged offender	Name
	Address
Details of alleged offence	Date or period
	Place
	Written law contravened
	Details of offence
Date	Date of notice
Authorised officer	Name
	Signature
Modified penalty	$_________
Due date for payment of modified penalty	/ /20 (Within 28 days after the giving of the notice)
TAKE NOTICE	It is alleged that you have committed the above offence. If you do not want to be prosecuted in court for the offence , pay the modified penalty to the Approved Officer* within 28 days after the date of this notice. If you do not pay the modified penalty within 28 days, you may be prosecuted or enforcement action may be taken under the Fines, Penalties and Infringement Notices Enforcement Act 1994 . Under that Act, some or all of the following action may be taken — your driver’s licence may be suspended, your vehicle licence may be suspended or cancelled, you may be disqualified from holding or obtaining a driver’s licence or vehicle licence, your vehicle may be immobilised or have its number plates removed, your details may be published on a website, your earnings or bank accounts may be garnished, and your property may be seized and sold. If you need more time to pay the modified penalty, you should contact the Approved Officer* at the address below. Paying the modified penalty will not be regarded as an admission for the purposes of any civil or criminal court case. If you want this matter to be dealt with by prosecution in court, sign and date here: __________________________________ / /20 and send this notice to the Approved Officer* at the address below within 28 days after the date of this notice. If you consider that you have good reason to have this notice withdrawn, you can write to the Approved Officer* at the address below requesting that this notice be withdrawn and setting out the reasons why you consider that this notice should be withdrawn. Your letter must be received not later than 28 days after the date of this notice.
How to pay	By post or email	Tick the relevant box below and send this notice to: WorkCover WA [Insert postal and email address]
		□         I want to pay the modified penalty. A cheque or money order (payable to [insert details of approved officer*] ) for the modified penalty is enclosed. □         I want to pay the modified penalty by credit card. Please debit my credit card account.
		Card type _____________________________ Cardholder name _____________________________________ Card number [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
		Expiry date of card _____/_____ Amount $__________ Signature ____________________ [Complete all details]
	By direct deposit	[Insert details]
	By electronic transfer	[Insert details]
*The following are approved officers for the purposes of receiving payment of modified penalties:
Method of service				Date of service

Form 2 ‑ Withdrawal of infringement notice

Workers Compensation and Injury Management Act 2023 WITHDRAWAL OF INFRINGEMENT NOTICE				Withdrawal no.
Alleged offender	Name
	Address
Details of infringement notice	Infringement notice no.
	Date of issue
Details of alleged offence	Date or period
	Place
	Written law contravened
	Details of offence
Approved Officer withdrawing notice	Name
	Signature
Date	Date of withdrawal
Withdrawal of infringement notice	The above infringement notice issued against you for the above alleged offence has been withdrawn. If you have already paid the modified penalty for the alleged offence, you are entitled to a refund.
[*Delete whichever is not applicable]	*         Your refund is enclosed.         or *         If you have paid the modified penalty but a refund is not enclosed, you may claim your refund by signing and dating this notice and sending it to: Approved Officer ‑ WorkCover WA [Insert postal and email address]
Your signature			Date