New Claim Call Back Form (SA) Please use this form to request a call back from Gallagher Bassett to notify of a new work related injury.If you are having difficulty completing this form or would like immediate assistance, contact our new claims team on 1800 774 177. Please note the 1800 774 177 number is only available during business hours. You can leave a voice message outside of hours for a call back by the close of the next business day. Hearing or Speech impaired? Call us via the National Relay Service (NRS).For languages other than English contact the Interpreting and Translating Centre on 1800 280 203 who can call us on 1800 774 177.The fields marked with an asterisk (*) below must be completed for this form to be submitted.TitleMsMissMrMrsDrYour name* Your contact number*Please enter your contact number including area code.Preferred day you'd like us to call you back (Monday - Friday)* MM slash DD slash YYYY Preferred time of the day you'd like us to call you back*8.30am - 10.30am10.30am - 12.30pm12.30pm - 2.30pm2.30pm - 5.00pmWhich best describes your relationship to the person injured?* I am their employer I am the person injured Other What is your business name? What is the full name of the person injured? What is your date of birth? MM slash DD slash YYYY Who is your employer? What is your relationship to the person injured?* Who is their employer? Captcha
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