Claim Form Help

Common Worker’s Injury Claim Form and Employer Injury Claim Report formats are now in use in NSW, QLD & VIC. The forms are uniform in terms of the questions for information and authorisations, consistent in appearance, but with front and back page information specific to individual states.

Please ensure the Victorian claim forms, identified by the Worksafe logo on the front page, are used to lodge claims in Victoria and complete all questions and authorisations except for those indicated as specific to NSW.

The following information will assist a person when completing the Worker's Injury Claim Form. Select from the below list to view relevant help information for each section:

• 1. Worker's Personal Details
• 2. Incident & Worker's Details
• 3. Worker's Employment Details
• 4. Worker's Primary Earning Details
• 5. Treatment & Return To Work Details
• 6. Authority to Release Medical Information and Worker's Declaration
• 7. Employer Lodgement Details

1. Worker's Personal Details

The following information may assist in completing the Worker's Personal Details section of the form.

Accurate personal and contact details are essential for timely assessment and management of your claim including the following additional information:

• Other known or previous legal names: If applicable provide full details of any previous or alias family and given names
• What are your daytime contact number/s? Provide most appropriate daytime contact number, mobile, work and /or home.
• Do you have special communication needs because of disability? Provide details of any impairment that may effect contact with you and identify assistance you may require in communication regarding your claim.

2. Incident & Worker's Details

The following information may assist in completing the Incident & Worker's Details section of the form.

Accurate details of the full extent of your injury and the causes of your injury are essential in managing your injury and return to work, and useful to help prevent further injuries.

The following information may assist in providing the level of detail required:

• What is your injury and which parts of your body are affected? Your Certificate of Capacity may be of assistance in describing your injury.
• What happened and how were you injured? This question is asking for the direct cause of your injury. In other words the sudden event or change that turned what you are doing into the situation in which you were injured.
• What task/s were you doing when you were injured? This question is asking what part of your job were you doing when injured.
• What area of the worksite were you in when you were injured? This question is asking in what part of the building, grounds, roadways or adjacent areas were you the injured.
• What is the street address where the incident occurred? Be as specific as you can when describing the address at which you were injured e.g. street number, name, suburb, postcode, level or floor (where applicable). This information can assist in preventing accidents like yours happening again.
• Name of the employer responsible for this workplace: Includes the name of the employer responsible for the workplace when different to your normal employer, for example a construction site, delivery location, contract placement employment etc.
• The police station the accident was reported to: If your workplace injury or illness related to or was caused by the driving of a motor vehicle on a public road, you must report the accident to police for your claim to be considered valid.
• Do you believe that your injury/condition was caused or contributed to by a third party such as a manufacturer or supplier? You are asked to assess whether you believe the events that resulted in your injury were: "an unavoidable accident" contributed to by someone or something (eg. a person or manufacturer's negligence, faulty equipment etc.) These answers assist us and your employer towards taking appropriate action against this type of incident occurring again.
• What was the date and time the injury/condition occurred? If your injury condition was the result of a sudden event/accident complete the date and time in the space provided
• When did you first notice the injury/condition? If your injury has arisen over a period of time (rather than as a result of a sudden event or accident) please provide the date you first noticed your injury/condition.
• If you stopped work, what was the date and time? The date and time you ceased work as a result of this injury/condition lets us know the date from which you are seeking compensation payments. If you did not cease work as a result of your injury print N/A in the space provided.
• When did you report the injury/condition to your employer? What is the name and position of the person you reported the injury/condition to? If you did not report the injury/condition, or there was a delay, please explain why. Your workplace should have a "Register of Injuries". You, or someone on your behalf, must report in writing your injury or illness within 30 days of becoming aware of it. If the injury or illness is not reported in writing within 30 days limit you may not be entitled to compensation so you need to provide the reasons for not reporting your injury.
• Have you previously had another injury/condition or personal injury claim that relates to this injury/condition? If you have experienced previous pain/disability in the area of your present injury/condition please provide:
  • When (date) this occurred.
  • What were your symptoms.
  • Description of how previous pain/disability occurred.
  • The treatment and medications provided.

   Also provide details of any personal injury claims for previous pain/disability.

3. Worker's Employment Details

The following information may assist in completing the Worker's Employment Details section of the form.

• Name of organisation paying your wages when you were injured: Name of employer paying your wages as identified on your payslip.
• Street address of your normal workplace (plus suburb & postcode): Address of your normal workplace (employer home base for workers who also work on other sites).
• Name and daytime contact number of employer contact e.g.Name of  return to  work coordinator: Name and daytime telephone number of employer contact in relation to your injury management, return to work and claim
• Did you have any other employment at the time you were injured? You only have to complete this section if you are employed by more than one employer or you are self employed outside your injury employer

 

4. Worker's Primary Earning Details 

The following information may assist in completing the Worker's Primary Earning Details section of the form.

• How many standard hours did you work each week before being injured? What was your usual pre-tax hourly rate? Exclude shift and overtime allowances: "Standard hours" means the core hours you regularly work that are paid at your base rate or normal pay rate.
• What were your usual pre tax weekly earnings? Exclude overtime & shift allowance: The question is asking for your average weekly income before tax that you were being paid at the time of your injury. If your weekly pay has varied throughout the 12 months leading up to your injury, you will need to look at what you were paid throughout this entire period. It may be easiest to obtain an accurate assessment of your pre-injury earnings from whoever manages the payroll at your place of employment.
• Please provide detail of any overtime or shift work: Subject to conditions, overtime and shift allowances maybe included in your weekly compensation payments (for the first 26 weeks of incapacity). If you have worked overtime or shift work in the 52 weeks before the date of injury, and it is likely that you would have worked overtime or shift work at some time in the next 26 weeks of incapacity if not for the injury. You should talk to your WorkSafe agent to establish if you have an entitlement.  

5. Treatment & Return To Work Details

The following information may assist in completing the Treatment & Return To Work Details section of the form.

• Please provide the name, clinic or hospital, and contact details of any medical providers (including clinics or Hospitals) that have treated your injury: Provide the contact details of your treating doctor/s and health practitioner/s. This information assists us in: "The initial evaluation of your claim." Ongoing management of your injury/condition such as discussing return to work and rehabilitation options with your doctor or treating health practitioner (such as a chiropractor, physiotherapist and osteopath).
• If you have returned to work with your employer, what was the date? If you have returned to work with your injury employer provide the date of return. If you have not returned leave blank
  • What duties are you doing? Full or Suitable/Modified: If you have returned to your pre - injury duties answer Full, if you have returned to alternative duties or modified duties in your pre-injury job, answer Suitable / Modified
  • How many hours are you working? Indicate the number of hours you are working per week.
• Have you returned to work with a new employer? Please provide the name and contact details of the new employer: If you have not returned to work with a new employer leave blank
• If you have not returned to work, do you think that there are any issues that would delay or prevent you from returning to work? If there are any issues that would delay or prevent return to work please record in this section. If there are no issues answer NO. If you have already returned to work leave blank 
• When did/will you give this claim form to your employer? How did/will you give this claim form to your employer? When did/will you give your employer the first medical certificate? This section provides information to your employer and WorkSafe agent as to the date you gave your claim and medical certificate to your employer, and how you delivered the claim (i.e. posted or hand delivered). If you are having difficulties giving your claim to your employer, as highlighted on the cover page of the Claim Form, indicate that your claim is being lodged under Section 106 of the Accident Compensation Act 1985. You must attach a note detailing/explaining why you are lodging the claim this way.

6. Authority to release medical information and worker's declaration 

You are required to sign the first authority and declaration provided on the form. The authority and declaration shaded in light blue is for NSW claims only

7. Employer Lodgement Details

This section must be completed, signed and dated by your employer. If possible, have your employer sign this section when you submit the form to them (if you do so in person).