Fillable Workers compensation claim form (Batchelor Institute of Indigenous Tertiary Education)

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Workers compensation claim form (Batchelor Institute of Indigenous Tertiary Education)

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Workers compensation claim form
15 September 2021
| Version 1.6
Page 1 of 8
Part 1
To be filled in by the worker. The following guidance is provided for workers filling in Part 1.
Notify your employer of your injury or disease verbally or in writing, as soon as practicable.
Fully complete Part 1, numbers 1 to 9, of the following claim form. The more information you provide
on the form, the quicker the claim can be progressed. If there is not enough space on the form to
include the relevant information, please use the space provided on the back page of this document.
Claims should be made within 6 months, however, in some circumstances a claim can be made later. If
you are unable to fill in this form and someone else does it for you, they must provide their details on
the form at the end of Part 1 number 9.
Sign and date the ‘Workers authority to release medical and relevant personal information and
declaration’ located at number 9 on the claim form. The claim will not be accepted without your
signature. You can sign using the following: by pen (hand-written); e-signature or electronic signature –
an image of your signature scanned and inserted in the signature section of the form; digital signature - an
encrypted digital code appended to the form to verify that it was created by a known source and has not been
altered. You cannot type your name in the signature block, even if this is converted to a stylish script.
You must obtain a NT Workers Compensation medical certificate of capacity – first from your treating
doctor and submit it with your claim form if you are claiming compensation for loss of income.
Keep a copy of your Workers Compensation Claim Form and any documents you have attached for
your own future reference.
If you are claiming compensation for medical expenses only, you need to provide the relevant accounts
or receipts with your claim form. You do not need to attach a ‘Medical certificate of capacity’.
Deliver your claim form by hand or mail or email to your employer as soon as possible. If you are
mailing the claim form then it is advisable to send it registered mail. If you are emailing the claim form
then it is advisable to request a delivery receipt.
What next
Once you have completed Part 1 of this form and given it to your employer, your employer must complete the
employers report Part 2, numbers 10 to 14. Your employer has 3 working days to submit the claim to their insurer.
The insurer has 10 working days after the employer received the claim from you, to make a decision and notify you.
The possible decisions are:
• Accept liability for the claim
• Defer accepting liability for the claim
• Dispute liability for the claim
The insurer will advise you of your rights and entitlements for the different types of decisions. If this does not
happen you can request that they do so, or contact NT WorkSafe for information.
Return to work
The purpose of workers compensation is to provide effective rehabilitation and economic support to injured workers.
It allows for prompt and effective management of workplace injuries in a manner that promotes and assists the return
to work of injured workers as soon as practicable and the effective rehabilitation of injured workers. You are
required to cooperate with reasonable medical, surgical and rehabilitation treatment and you must participate in the
return to work process.
The role of NT WorkSafe
The role of NT WorkSafe is to administer and enforce the Return to Work Act 1986. NT WorkSafe provides a claims
mediation service and will arrange a medical panel for disputed permanent impairment assessments. Claims are
managed by approved insurers and self-insurers. NT WorkSafe has no legislative power to review claims decisions
made by insurers. This power rests with the Work Health Court.
Disputes
Should you disagree with any decision made by the insurer regarding your workers compensation claim, please
contact the insurer for information on their internal dispute resolution process or contact NT WorkSafe for
information on mediation and dispute resolution procedures on 1800 250 713 or visit NT WorkSafe website.
Further information is available on the NT WorkSafe website, www.worksafe.nt.gov.au
or by calling NT WorkSafe toll
free number 1800 250 713 (Australia wide).
Workers compensation claim form
NT WorkSafe
15 September 2021
| Version 1.6
Page 2 of 8
Part 2
To be filled in by the employer. The following guidance is provided for employers filling in Part 2.
Have you notified NT WorkSafe if the incident is a ‘notifiable incident’? Failing to notify is an offence
and penalties may apply, see note 1 below.
When you receive the claim form from your worker, you must complete Part 2, numbers 10 to 14 of
the form.
Check your worker has signed the ‘Workers authority to release medical and relevant personal
information and declaration’ at number 9 of the claim form.
Forward the claim form within 3 working days to your insurer, together with the NT Workers
Compensation medical certificate of capacity – first (if applicable) and any other attached documents.
For example, medical receipts or accounts. If a decision as to liability for the claim is not made by the
insurer within10 working days of you receiving the form, liability is deemed to be accepted. A claim
may subsequently be disputed.
Keep a copy of the claim form and attached documents for your own future reference.
If the injured worker is unable to complete a claim form, please arrange for a claim form to be
completed on their behalf.
If a worker has died due to a work related injury or disease, do not fill in this claim form, instead please
contact NT WorkSafe on our toll free number 1800 250 713 (Australia wide).
If liability is accepted or deferred, and there is time lost, payments must commence to the worker
within 3 working days of the decision. Your insurer will instruct you in this process. Subsequent
payments should be made on a worker’s normal pay day.
Send other medical certificates and accounts to your insurer as they become available.
NT WorkSafe
NT WorkSafe does not have a claims management role and employers should liaise with their insurer for information
about the claims process and the calculation of weekly compensation.
Insurers
Insurers will provide employers with all the information needed to meet their obligations.
Return to work
The purpose of workers compensation is to provide effective rehabilitation and economic support to injured workers
and provides for prompt and effective management of workplace injuries in a manner that promotes and assists the
return to work of injured workers as soon as practicable.
The employer must take all reasonable steps to provide the injured worker with suitable employment, and when
necessary, so far as is practicable, participate in efforts to retrain the worker. Refer to ‘Rehabilitation – A Guide for
Employers’ available on the NT WorkSafe website.
If the employer is unable to provide the worker with suitable employment then the employer, in consultation with the
insurer, must refer the worker to the alternative employer incentive scheme. Refer to information bulletin
‘Alternative Employer Incentive Scheme’ available on the NT WorkSafe website.
Further information
Further information is available on the NT WorkSafe website, www.worksafe.nt.gov.au
or by calling NT WorkSafe toll
free number 1800 250 713 (Australia wide).
Explanatory Note 1 for employers completing this form
Note 1 (number 10 of the claim form)
The Work Health and Safety (National Uniform Legislation) Act (WHS Act) requires the regulator (NT WorkSafe) to be
notified of certain ‘notifiable incidents’. In summary Part 3 of the WHS Act requires:
• Immediate notification of a ‘notifiable incident’ to the regulator after becoming aware of it by calling
1800 019 115 (this number can be used 24 hours a day)
• If the regulator asks, written notification must be given within 48 hours of the request. This must be
provided in the approved ‘Incident Notification Form’ available on the NT WorkSafe website.
• Preservation of the incident site until an inspector arrives or directs otherwise. This is subject to some
exceptions.
Failing to notify is a criminal offence and penalties apply. Further information on what is a notifiable incident can be
found in information bulletin ‘Notification of Incidents’ available on the NT WorkSafe website.
Workers compensation claim form
NT WorkSafe
15 September 2021
| Version 1.6
Page 3 of 8
NT Workers Compensation Claim Form
Section 82(1)(a) of the Return to Work Act 1986 requires a claim for compensation be in a form approved by the Authority. This is the approved form for a Workers
Compensation Claim, other than death. There is a separate approved form for death claim by dependents.
Insurer Claim No
This panel must be completed by the insurer
Work Health Claim No
Date claim form received:
Date worker notified:
Accept
Deny
Defer
Reason:
Worker to fill in Part 1, numbers 1 to 9 and then give to their employer to complete Part 2 numbers 10 to 14
Part 1 – Workers report on injury or disease
1.
Worker details
Title:
Mr
Mrs
Ms
Miss
Mx
Last, surname, family name:
First or given name:
Other names you have been known by:
(for example maiden name
)
Gender:
Male
Female
Gender diverse
Date of birth:
Age:
Home address:
Suburb:
State:
Postcode:
Postal address:
Suburb:
State:
Postcode:
Home number:
Mobile number:
Work number:
Email address:
Country of birth:
Language spoken at home:
Marital status:
Single
Married
De facto
Dependants:
Spouse:
Yes
No
Children:
Yes
No
Number of children:
Dates of birth:
2.
Workers job
Name of employer at time of injury or disease:
Your occupation and job title at time of injury or disease:
At the time of the injury I was working as a:
Direct employee
Working director
Employee of contractor
Contractor
Sub-contractor
Visa worker
Other (please specify)
Are you an apprentice or trainee:
Yes
No
Are you:
Full time
Part time
Permanent
Temporary
Casual
Do you have other paid employment:
Yes
No
If yes
, give full name and address of employer: Name:
Address:
Suburb:
State:
Postcode:
3.
About the claim
Where did the injury or disease occur: please cross
A.
At the workplace at which I am normally based
B.
Working elsewhere
C.
While I was having a break
D.
Travelling to or from work
F.
Attending training school
J.
Travelling whilst on duty
Q
At work – working from home
Other: give details
Exact location or address the injury or disease occurred:
When did injury or knowledge of
the disease first occur:
Date:
Time: am
pm
Workers compensation claim form
NT WorkSafe
15 September 2021
| Version 1.6
Page 4 of 8
Part 1 – Workers report on injury or disease continued
4.
About the incident
What were you doing at the time - how did the injury happen or what caused the disease. Include any object or
substances involved. For example grinder, saw or drill.
Note: if insufficient space, use the space provided on the back page
of this form.
5.
About the injury or disease
Part of body affected:
Type of injury or disease:
for example fracture, burn
If more than one injury which is the most serious:
6.
Witness
Name and contact details of any person who was present at the time of injury:
Person name:
Address:
Suburb:
State:
Postcode:
Home number:
Mobile number:
Work number:
Email address:
7.
Other information
Did you report the injury or disease to your employer:
Yes
No
If
no, reason not reported:
If yes:
Date
Time
am
pm
Name of person reported to:
Persons position in the company:
Did you stop work because of your injury or
disease:
Yes
No
If yes:
Date
Time
am
pm
Time you started work that shift:
Time am
pm
If you stopped work have you started back at work:
Yes
No
If yes
: Date
Did you receive any medical treatment following your injury or disease:
Yes
No
If yes, give full name and address of treating professional:
Professional name:
Address:
Suburb:
State:
Postcode:
Dates you were treated:
Were you admitted to hospital:
Yes
No
If yes
, give full name and address of hospital:
Hospital name:
Address:
Suburb:
State:
Postcode:
Workers compensation claim form
NT WorkSafe
15 September 2021
| Version 1.6
Page 5 of 8
Part 1 – Workers report on injury or disease continued
Are you still receiving treatment:
Yes No
If yes, give full name and address of person treating you:
Person name:
Address:
Suburb: State: Postcode:
What are you claiming for:
Time off work, other than the day of injury
Yes
No
If claiming for time off work,
you must provide an
NT
medical certificate of
capacity – first
Medical expenses, surgical, rehabilitation, hospital
Yes
No
Have you suffered a similar injury or disease before:
Yes
No
If yes
, give full name and address of previous treating professional:
Professional name:
Address:
Suburb:
State: Postcode:
Type of injury or disease:
Date injury or disease occurred:
Have you previously claimed workers compensation for the same or similar injury:
Yes
No
When was the compensation claim made
(date):
Employers name:
Name of insurer: (if know)
8.
Previous employer
Could the injury or disease described in this claim have occurred in previous employment:
Yes
No
If
yes, name of previous employer:
Employer suburb or town:
Period of employment:
Name of insurer: (
if known)
9.
Workers authority to release medical and relevant personal information and declaration
This authorisation and declaration must be signed or your claim will not be considered by the insurer
I authorise and consent to any person who provides me
with a
medical or hospital service, if requested by my employer or their
insurer or the employer or insurer’s appointed service providers,
for the disclosure and release of information regarding the service
that is relevant to the injury or disease for wh
ich I have made a
workers compensation claim.
This authorisation and consent extends to the collection,
disclosure and release of any health and related personal
information that is relevant to the injury or disease for which I
have made a claim, by my emp
loyer or their insurer or the
employer or insurer’s appointed service providers, including the
disclosure and release of such information to each other, and/or
to one or more of the following: the Work Health Authority (NT
WorkSafe), a legal practitioner,
medical practitioner, investigator,
accredited vocational rehabilitation provider, or any other person
reasonably consulted by the employer or insurer for making a
decision as to payment of the claim for compensation.
I consent to NT WorkSafe using the inf
ormation collected in
connection with my claim to fulfil its obligations under the
Return to Work Act 1986
or for the purposes of research about
workers compensation, workplace injury management and work
health and safety.
I understand that if this claim
results in my receiving weekly
compensation payments, I am required to notify the party
paying my benefits if I commence employment with some other
person, and that failure to do so is an offence.
I have read the information provided in this form. I declar
e that
the information supplied in this form, and any attachments to
this form, is true and correct to the best of my knowledge. I
understand that making a misleading statement or giving a
document that contains misleading information is an offence.
Pleas
e complete all fields in this section using printed ALL CAPITAL letters, other than your signature.
See page 1 of this form for information on how your signature may be provided.
First Name:
Surname:
Date of birth:
Date of injury:
Type of injury or disease:
Signature:
Date:
Date that claim form forwarded to employer:
Posted
By hand
Emailed
9A.
If you are completing this claim form for the injured or diseased person, complete:
Name:
Address:
Suburb:
State:
Postcode:
Now that you have completed Part 1 numbers 1 to 9, forward your claim form to your employer
If claiming for time off work, include the NT medical certificate of capacity– first
click to sign
signature
click to edit
Workers compensation claim form
NT WorkSafe
15 September 2021
| Version 1.6
Page 6 of 8
Within 3 days the employer must complete the following numbers 10 to 14 and forward to insurer
Part 2 – Employers report on injury or disease
10.
Notifiable incident – see note 1 on page 2 at the front of this form
Is this injury or disease the result of an incident required to be notified to NT WorkSafe:
Yes
No
If
yes, date of notification:
Reference number given by NT WorkSafe:
11.
Employer information
Business
entity name:
Business trading name: (
if different from above)
Australian Business number: (
ABN)
Australian Company Number:
if applicable
Address for correspondence:
Suburb:
State:
Postcode:
Work number:
Mobile number:
Fax number:
Email address:
Name of person who can be contacted in relation to this claim:
Position in the business:
Date claim received from worker:
12.
Workers compensation insurance policy information
What is your workers compensation insurers name:
What is the
policy number:
What is the expiry date on policy:
13.
About the injured or diseased worker
What was the workers gross weekly remuneration before the injury or disease:
$
Does this gross weekly remuneration include allowances:
Yes
No
If
yes, please provide details below:
How many hours does the worker normally work each week:
Hours:
Does the worker normally work overtime or shift work:
Yes
No
Is the worker provided with benefits not paid by money or a credit for accommodation, meals
or electricity:
Yes
No
If yes, what is the market value to the worker:
$
Is the worker a fly in fly out or drive in drive out worker:
Yes
No
Where within your establishment does the worker normally work: (your answer here must tell us the actual section
and address of the workplace location where the worker does the majority of his or her work. If the worker works at
multiple locations, tell us where the worker is normally based)
Section where worker normally works:
Normally based location address:
Suburb:
State:
Postcode:
Workers compensation claim form
NT WorkSafe
15 September 2021
| Version 1.6
Page 7 of 8
Part 2 – Employers report on injury or disease - continued
How many people are employed at this particular
location: (at the normally based location address, at the present time)
1 to 4
5 to 9
10 to 19
20 to 49
50 to 99
100 to 199
200 to 499
500 plus
When was the worker first employed by you:
Is the worker a contractor:
Yes
No
Is the worker temporarily in Australia on a visa:
Yes
No
If yes
, expiry date on visa:
What is the type of industry at the establishment where the worker normally works: (you must state the main type of
activity, business or service you provide in which the injured worker was involved. You do not put the actual
occupation of a worker, for example, if you are a gold mining company and the injured worker is a driver,
put down
gold mining)
14.
Declaration
I have read the information provided in this form. I declare that the information supplied in this form, and any
attachments to this form, is true and correct to the best of my knowledge. I understand that making
a misleading
statement or giving a document that contains misleading information is an offence.
Name: of person who has filled in Part 2 numbers 10 to 14
Signature:
Date:
Position in the business:
Date that claim form forwarded to insurer:
Posted
By hand
Emailed
Now that you have completed Part 2 sections 10 to 14,
forward the claim form and any supporting documents to your insurer
click to sign
signature
click to edit
Workers compensation claim form
NT WorkSafe
15 September 2021
| Version 1.6
Page 8 of 8
Additional information to workers compensation claim form
Part 1 – Workers report on injury or disease
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Workers compensation claim form (Batchelor Institute of Indigenous Tertiary Education)

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Completed 18 November 2021

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