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
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
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
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
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?
What date and time did the injury occur?
What date and time did the worker first cease work?
* For NSW incidents a journey claim form must also be completed