When did the employer first receive
the worker’s completed claim form?
When did the employer first receive
the worker’s medical certificate?
*This question is required for Victorian claims
Date claim form forwarded to Agent
Estimated cost of claim to date
How many days have been lost?
Employer’s signature Date
Name
Position
Employer’s scheme registration number
eg. WorkCover Employer, Policy, or Employer Registration Number
7 EMPLOYER LODGEMENT DETAILS
days hrs
Name of organisation paying your wages when you
were injured
Street address of your usual workplace
Suburb
State Postcode
Name and daytime contact number of employer contact
eg. Name of return to work coordinator
What is your usual occupation? What do you do?
Which of the following apply to you?
(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 you start working for this employer?
Please indicate if any of the following apply to you:
Yes No A Director of my employer’s company
Yes No A Partner in my employer’s company
Yes No A sole trader
Yes No A relative of my employer
Did you have any other employment at the time you were
injured? Please provide or attach the names of any other employers and their
contact details, and any relevant wage or payment records
Please provide the name, clinic or hospital, and contact details
of any medical providers (including Clinics or Hospitals) that
have treated your injury
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
hrs
hrs
* This question is required for NSW claims
* Who is your nominated treating doctor?
Name Phone
If you have returned to work with your employer,
what was the date?
What duties are you doing? Full Suitable/Modified
How many hours are you working?
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, do you think that there
are any issues that would delay or prevent you from returning
to work?
When did/will you give your employer this claim form?
How did/will you give this claim form to your employer?
Hand delivery By post
When did/will you give your employer the first medical
certificate?
hrs
This form can be used to lodge a Workers’ Compensation Claim in New South Wales, Queensland, or Victoria
I have read the information provided in this form. I declare that the information that I
have supplied in this form, and any attachments to this form, is true and correct to the
best of my knowledge. I understand that the making of a false or misleading claim or
false and misleading statement in support of the claim is punishable by law and that I
may be prosecuted.
I authorise and consent to any person who provides a medical service or hospital service
to me in connection with an injury/condition to which this claim relates to provide upon
request by the workers’ compensation authority, my employer or insurer/claims agent,
any information regarding the service relevant to the claim. I understand that my
authority has effect and cannot be revoked for the duration of this claim.
Worker’s signature Date
* This declaration is also required for NSW claims
I authorise and consent to the collection, disclosure and release of any personal
and health information in connection with an injury/condition to which the claim
relates by the workers’ compensation authority, my employer or insurer/claims
agent to each other, or to any person who provides a medical service or hospital
service to me in connection with an injury/condition to which this claim relates.
I understand that if this claim results in my receiving weekly compensation
payments, I am required to notify whomever is paying my benefits if I commence
employment with some other person or in my own business, or of any change in
my employment that affects my earnings, and that failure to do so is an offence.
I consent to the WorkCover Authority of NSW using the information collected in
connection with my claim for the purposes of research about workers
compensation, workplace injury management and occupational health and
safety.
Worker’s signature Date
Please complete this section if you wish to claim for weekly payments
How many standard hours did you work each
week before being injured? Exclude overtime
What were your usual working hours?
For example, Monday to Friday, 8.30 am to 5.30 pm
What was your usual pre-tax hourly rate?*
Exclude overtime & shift allowances
What were your usual pre-tax weekly earnings?*
Exclude overtime & shift allowances
* Please provide copies of any recent payslips (if available)
Please provide details of any overtime or shift work
Weekly shift allowance
Weekly overtime
