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INJURY CLAIM REPORT EMPLOYER WORKSAFE VICTORIA (Department of Infrastructure, Transport, Cities and Regional Development)

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EMPLOYER
INJURY CLAIM REPORT
WORKSAFE VICTORIA
This report can be used to lodge a Workers’ Compensation Claim in New South Wales, Queensland, or Victoria.
FOR589/10/12.16
The Agent will write to you and advise you if the claim has been accepted.
A decision to accept or reject the worker’s claim will usually be made within 28 days from the time the claim is received by the Agent.
To find out more about the process of making a claim, and what assistance is available to support the return to work process, talk to
your Agent, refer to the brochure What to do if a Worker is Injured, a Guide for Employers, or visit the website at worksafe.vic.gov.au.
• To notify you that they’ve been injured at work as soon as possible, and complete the injury register at the workplace.
• To report the accident to the police if the injury was the result of a motor vehicle accident. Otherwise their claim may not be valid.
• To see their medical practitioner to obtain a WorkSafe Certificate of Capacity (medical certificate) if they want to claim weekly
compensation payments, and to give you a copy along with their claim form.
• To give you the completed Workers’ Injury Claim Form and any WorkSafe Certificates of Capacity (medical certificates) as soon as
possible after being injured. If your worker has difficulty giving you their claim form or any WorkSafe Certificates of Capacity to you,
or you refuse to take receipt of these documents, the worker has the right to lodge the claim directly with the Agent. The worker
can also notify the Agent or WorkSafe directly by sending them the “Early Notification” copy of the Worker’s Injury Claim Form.
• To work with you to develop a return to work plan (if required).
✓ Sign the employer’s declaration at the end of this form. The form cannot be accepted without your signature
✓ Keep a copy of all documents for your records
✓ Confirm with your worker in writing that you’ve been notified of this claim (you can do this by giving them a copy of the Worker’s
Injury Claim Form when signed)
✓ If the claim includes weekly payments, send this completed form, the completed Worker’s Injury Claim Form, and any WorkSafe
Certificate of Capacity (medical certificates) to your Agent as soon as possible, but no later than 10 days after receiving them from
your worker - or you may be financially penalised
✓ If the worker has an entitlement to compensation and the claim is accepted, pay the worker weekly payments,
✓ Pay the worker’s initial medical and treatment expenses, up to the level specified by your WorkSafe policy. If this threshold is
exceeded, forward this report, the claim form, copies of accounts paid, and any unpaid accounts to your Agent within 10 days
• Your WorkSafe Victoria (WorkSafe) Agent
• The WorkSafe Advisory Service: freecall 1800 136 089 or (03) 9641 1444
FOR HELP COMPLETING THIS FORM OR FOR MORE INFORMATION CONTACT:
AS THE EMPLOYER YOU NEED TO:
For more information on your employer return to work obligations, and how you can assist your worker to return to work, refer to
the back of this form or visit the website at worksafe.vic.gov.au and click on injuries and claims, then returning to work.
• Talk with your worker to plan for their return to work as soon as you receive their claim form or WorkSafe Certificate of
Capacity (medical certificate)
• Talk to your worker’s medical practitioner or healthcare provider about your worker’s limitations, what parts of their work
they could do and any suitable duties that you may have available. This can help inform the medical practitioner or
healthcare provider when they review and evaluate your worker’s capacity for work.
• Talk to your Agent about what support is available to help your worker return to work and overcome their injury as quickly
as possible.
• When your worker has some capacity for work, provide them suitable employment. When they no longer have an incapacity
for work, provide them with their pre-injury employment.
• Appoint a return to work coordinator who is competent to help you meet your return to work obligations and support the
worker’s return to work
GETTING YOUR WORKER BACK TO WORK
✓ Make sure you provide your Agent with full details of your worker’s earnings, this can include a pay slip, payroll report or other
document with earnings details. A form is available on the WorkSafe website which will help you accurately declare all of your
worker’s earnings. Please refer to the back page of this form for more information about a worker’s earnings.
YOUR WORKER’S RESPONSIBILITIES:
✓ Answer all of the questions on this form. Carefully complete this form USING A DARK BLUE or BLACK PEN. The form may be
returned to you if it is incomplete
Family name
Given names
Street address
Suburb Postcode
Daytime contact phone number/s
Date of birth Gender
Male Female
Street address of the worker’s usual workplace
Suburb
State Postcode
If the incident did NOT happen at one of your workplaces,
please give the name of the employer responsible for
the workplace
Employer’s name
What is the worker’s usual occupation?
What are the main tasks performed by the worker in their
usual occupation?
Which of the following apply to the worker?
(Please tick all relevant boxes)
Casual Student
Full-Time Part-Time Apprentice Volunteer
Contract Trainee Agency worker Contractor
Permanent Temporary Seasonal Jockey
Other?
When did this worker start working for you?
Legal name
Trading name
Employer’s scheme registration number
eg. WorkSafe Employer, Policy, or Employer Registration Number
Employer’s reference number (Your reference)
Street address
Suburb
State Postcode
Postal address
Australian Business Number
ACN/ARBN
Division Cost Centre
What is the main business activity at the incident site?
Name, position, and daytime contact number
of employer contact
Name and daytime contact number of the return to
work coordinator (if any)
Address for correspondence relating to this claim
Postal address
State Postcode
Employer contact e-mail address
If you need an interpreter, what language do you speak?
When did you receive the worker’s completed claim form?
When did you receive the worker’s first medical certificate?
1 EMPLOYER’S DETAILS
3 WORKER’S EMPLOYMENT DETAILS
M W H
* This question is required for NSW claims
* Policy period of insurance
to
This question is required for NSW claims
How many workers are employed at this workplace?
This question is required for Victorian claims
Workplace number for worker’s usual workplace
* These questions are required for NSW and QLD claims
Is the worker employed under any of the following?
Federal award Registered industrial agreement
State award No agreement or award
WCA Jobcover Program Registered enterprise agreement
* What is the title of the award or agreement?
4 WORKER’S RETURN TO WORK DETAILS
If the worker has returned to work, please provide the date
What duties are they doing? Full Suitable/Modified
2 WORKER’S DETAILS
This report can be used to lodge a Workers’ Compensation Claim in New South Wales, Queensland, or Victoria
What is the worker’s minimum weekly wage?
As specified by the award or agreement
EMPLOYER INJURY CLAIM REPORT
Please indicate in which State you want to lodge this claim:
New South Wales Queensland Victoria
FOR589/10/12.16
PLEASE COMPLETE FORM USING A DARK BLUE or BLACK PEN
I have read the information provided in this form. I declare that the information
I have supplied in this form, and any attachment to this form, is true and correct and
that no information has been suppressed or omitted from this report to the best of
my knowledge. I understand that the making of a false or misleading statement
concerning a claim is punishable by law and that I may be prosecuted.
Signature of employer’s representative Date
Name
Position
Which of the following incident circumstances apply?
While working at the usual workplace
While working away from the usual workplace
During a meal-break or authorised recess at work
While away from work during a recess
Travelling to or from work*
A motor vehicle accident while working*
If the injury was the result of driving or using a motor vehicle
or the use of public transport, please provide the registration
number/s of any vehicles involved
State
Has the worker had a similar injury/condition or personal
injury claim before that relates to this injury/condition?
Please give details, including claim numbers
When did the worker report the injury to you?
Who was the injury reported to?
What are the names and daytime contact details of
any witnesses?
Do you believe that the injury/condition was caused or
contributed to by the worker, or a third party such as a
manufacturer or supplier? Please give details if relevant
Do you want to provide any additional information that may
assist in the determination of liability or the management of
this claim? eg. Do you dispute liability, and, if so, why?
7 INCIDENT DETAILS
8 ADDITIONAL INFORMATION
9 EMPLOYER’S DECLARATION
How many hours do they work each week?
How many days have been lost?
Have you provided the worker with a return to work plan,
taking into account the injury/condition?
Please attach a copy of the return to work plan or agreement, or please explain why
you have not provided a plan.
If the worker has not returned to work, do you know of any
issues that would delay or prevent a return to work?
5 CLAIM CONFIRMATION DETAILS
Do you agree that the details
provided in sections 2 & 4 of the
Worker’s Injury Claim Form
are correct? Yes No
Do you accept that your worker has an
injury/condition which is work-related
and occurred while in your employment? Yes No
Note: If you agree the injury is work-related, and believe that the details provided in
sections 2 & 4 of the Worker’s Injury Claim Form are correct, you do not need to
complete the remainder of this form except for section 9, which MUST be completed.
Otherwise, please complete any relevant questions in sections 6, 7 and 8 of this Report.
6 WORKER’S EARNING DETAILS
Please complete this section if you wish to claim for weekly payments
How many standard hours did the worker work
each week before being injured? Exclude overtime
What were the worker’s usual working hours?
For example, Monday to Friday, 8.30 am to 5.30 pm
What was the worker’s usual gross hourly rate?
Exclude overtime & shift allowances
What was the worker’s usual gross
weekly earnings? Exclude overtime & shift allowances
Please provide details of any overtime or shift work
Average weekly overtime
Weekly shift allowance
Please provide payroll records covering the 12 months prior to injury
hrs
hrs
This report can be used to lodge a Workers’ Compensation Claim in New South Wales, Queensland, or Victoria
What is the worker’s injury/condition, and which parts of the
body are affected?
What happened and how was the worker injured?
What is the street address where the incident occurred?
Suburb
State
What date and time did the injury occur?
AM
PM
What date and time did the worker first cease work?
AM
PM
hrs
days hrs
* For NSW incidents a journey claim form must also be completed
days hrs
INFORMATION FOR EMPLOYERS AND RETURN TO WORK COORDINATORS (RTWC)
GETTING YOUR INJURED WORKER BACK TO WORK:
• You must commence planning your worker’s return to work as soon as you receive their claim for weekly payments or
WorkSafe Certificate of Capacity (medical certificate), even if they do not have a current capacity for work.
• Planning involves obtaining relevant information about your worker’s capacity for work and considering reasonable
workplace support, aids or modifications. It also involves assessing and proposing suitable employment options, and
consulting with your worker, their medical practitioner or healthcare provider and occupational rehabilitation provider (if one
is involved).
• If you need assistance with return to work planning or assessing suitable employment options, contact your Agent
immediately. Your Agent may approve the use of an Occupational Rehabilitation provider to help you.
• Send the proposed suitable or pre-injury employment options to the worker’s medical practitioner or healthcare provider.
This will help them understand the availability of suitable employment, and inform them when making an assessment of the
worker’s capacity for work.
• WorkSafe’s Return to Work Proposal template may assist you to communicate these suitable or pre-injury employment
options to the medical practitioner or healthcare provider.
• Ideally a return to work proposal would be signed by all parties to indicate their support, however it is not mandatory.
• You must provide your worker with clear, accurate and current details of their return to work arrangements, and regularly
review and update these as your worker’s condition will change over time.
• When your worker has some capacity for work, you have a legal obligation to provide them with suitable employment. When
they no longer have an incapacity for work, your legal obligation is to provide them with their pre-injury employment.
Employers who do not meet these obligations risk penalties, including fines and prosecutions in the courts.
FURTHER INFORMATION AVAILABLE TO SUPPORT YOUR RETURN TO WORK PLANNING
You can obtain information, forms, publications and factsheets to help you plan a worker’s return to work from our website,
worksafe.vic.gov.au. Click on ‘Injury and Claims’ then ‘Returning to work’.
This information includes:
• What to do if a worker is injured - a guide for employers
• useful tools and templates to help you assess and propose suitable employment, and clearly set out a worker’s return to
work arrangements.
You can also contact your Agent for further advice and guidance about return to work planning and preparation.
ADDITIONAL SUPPORT FOR RETURN TO WORK COORDINATORS
Material, guidance and training are available to help return to work coordinators fulfil their role and assist their employer meet
their return to work obligations. For further information, visit the WorkSafe website worksafe.vic.gov.au
Return to Work Coordinators can also sign up to the WorkSafe Return to Work Coordinator Register. This enables Return to Work
Coordinators to receive key information on:
• Return to Work Coordinator training
• Return to Work Employer networks
• new return to work forms, publications and information
• legislative changes impacting return to work processes and requirements
Registration is voluntary but is strongly encouraged. Register at http://rtw.worksafe.vic.gov.au
CALCULATING ENTITLEMENT TO WEEKLY PAYMENTS
Weekly payments are calculated based on the worker’s pre-injury average weekly earnings (PIAWE) for the 52 weeks before
their injury. If they have been employed by you for less than 52 weeks, their average weekly earnings for the period of
employment are used.
What you need to provide about your worker’s earnings
So that the Agent can calculate the worker’s PIAWE, you will need to provide details of any of the following payments that you
have made to the worker in the 52 weeks before the injury (or if the period of employment was less than 52 weeks, in the
period of actual employment).
• Worker’s base rate of pay
• Overtime and shift allowances paid
• Piece rates, tally bonuses and commissions paid
• Non-pecuniary benefits including residential accommodation, use of a motor vehicle, payment of health insurance or
payment of education fees
• Any salary sacrifice arrangements
You will also need to tell the Agent of any promotion or voluntary demotion of the worker in the 52 week period before the
injury. If your worker’s earnings include any of the items listed above, and are not captured in part 6 of this form you can
complete the Calculating Pre-Injury Average Weekly Earnings form that is available on the WorkSafe website,
worksafe.vic.gov.au
to ensure you have provided all the worker’s earnings details.
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INJURY CLAIM REPORT EMPLOYER WORKSAFE VICTORIA (Department of Infrastructure, Transport, Cities and Regional Development)

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Completed 3 January 2021

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