Claim for Compensation Following a Work-related Death

  • Claim for Compensation Following a Work-related Death (DOC 2.92MB)
    Document Type: Form
    Keycode: FOR504/04/05.13
    Category: Injury and Claims 
    Publication Date: 5 September 2013
    Version: 4.0 
    Summary: This form can be used to claim compensation entitlements if you have incurred medical and like expenses (including burial or cremation costs) as a result of the work-related death of a worker and/or you were dependent on the income of the deceased worker at the time of death.

About this form

This form should be used if you wish to claim compensation entitlements because you have incurred medical and like expenses (including burial or cremation costs) as a result of the work-related death of a worker and/or you were dependent on the income of the deceased worker at the time of death.  You will need to complete and sign the claim form then lodge the completed claim form with the deceased worker's employer or the employer's WorkSafe Agent.  If you don't know who the employer or Agent is, call the WorkSafe Advisory Service on free call 1800 136 089 or email info@worksafe.vic.gov.au

Where to send the form

Give the completed and signed claim form to the employer. If you have difficulty lodging the claim with the employer, call the Agent or the WorkSafe Advisory Service. The employer must forward the claim to the Agent within 10 days of receiving the claim. If you wish to check the progress of the claim after this time, please contact the Agent.

Further information


Information on how to make a claim for compensation entitlements following a work-related death can be obtained from the WorkSafe Advisory Service on free call 1800 136 089 or via email info@worksafe.vic.gov.au