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Worker Injury Claim Form

  • Worker's Injury Claim Form (PDF 230kb)
    Document Type: Form
    Keycode: FOR502/10/11.13
    Version: 10
    Category: Injury and Claims, 
    Publication Date: 04 June 2014
    Date First Published: 11 October 2006
    Summary: This form is to be completed if you intend to make a claim for compensation for a work-related injury or illness.

About this form

If you suffer a work-related injury or illness, you, or someone else if you are unable to, must report it to your employer as soon as possible. If you haven't notified your employer in writing within 30 days of becoming aware of the injury, you may not be entitled to compensation.

A claim for weekly payments must be given, served or lodged as soon as practicable after the incapacity arising from the injury or condition becomes known, and a claim for compensation for medical and like services must be made within six months after the date of the relevant service.

What you will need

When completing this claim form you may want to have the following information at hand:

  • Details about your earnings (i.e. your hourly rate, pre-tax weekly earnings, shift/overtime allowances, any other income)
  • If your injury was the result of a motor vehicle accident you must report it to the police. You will be required to provide details of the police station and/or officer the accident was reported to
  • If you are making a claim for weekly payments you will also be required to provide a WorkSafe Certificate of Capacity

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 sign the Authority to release medical information and worker's declaration at the end of the form. The claim form cannot be accepted without your signature.

If you require assistance in completing your claim form

If you are unsure about how to complete the claim form, or if you need assistance you can contact:

  • Your employer or the Return to Work Coordinator at your workplace
  • WorkSafe Advisory Service – freecall 1800 136 089 or (03) 9641 1444
  • Your employer's WorkSafe Agent – to find out who iyour employer's Agent is, check the If you are injured poster in your workplace or call the WorkSafe Advisory Service

Your union or Union Assist – a free service set up and run by the Victorian Trades Hall Council: (03)9639 6144

Where to send the form

Give the completed and signed claim form to your employer as soon as possible after being injured. After your employer has signed and dated the claim form, keep a copy for your own records. Your employer must forward your claim to your WorkSafe Agent within 10 days of receiving it.

After you have given a claim for compensation to your employer, you can notify your WorkSafe Agent of the claim by sending them a copy of the claim form and medical certificate.

If you have difficulty giving your claim to your employer, or your employer refuses to take receipt of the claim form, you can send it directly to the WorkSafe Agent or WorkSafe if the Agent is not known.