Employer Injury Claim Report

  • Employer Injury Claim Report (PDF 220kb)
    Document Type: Form
    Keycode: FOR589/09/10.10
    Category: Injury and Claims, 
    Publication Date: 01 November 2010
    Date First Published: 11 October 2006
    Summary: This form is to be completed upon receipt of a Worker's Injury Claim Form for weekly payments and/or medical and like expenses, and upon receipt of a Dependant's Claim for Compensation.

About this form

An Employer Injury Claim Report is to be completed upon receipt of a Worker's Injury Claim Form for weekly payments and/or medical and like expenses, and upon receipt of a Dependant's Claim for Compensation.

Related information

If you fail to forward a worker's claim and all forms as required, you may be legally required to pay an additional amount and/or a penalty, and any interest owing to the worker.

How to complete the form

You may complete this claim form by:

  • printing the form and filling in the information clearly using a ballpoint pen

Please complete all questions on the claim form.

Once it has been completed you must send it, along with the Worker's Injury Claim Form (or Dependant's Claim for Compensation) and any other information relevant to the claim (eg VWA Medical Certificate) to your VWA Agent.

If you have any problems about the claim you should first talk to your VWA Agent. If you are still not satisfied, telephone the VWA Advisory Service on (03) 9641 1444 or freecall on 1800 136 089.

Where to send the form

Forward claims to your VWA Agent.