Employer Claim Report Help

Common Worker’s Injury Claim Form and Employer Injury Claim Report formats are now in use in NSW, QLD & VIC. The forms are uniform in terms of the questions for information and authorisations, consistent in appearance, but with front and back page information specific to individual states.

Please ensure the Victorian claim forms, identified by the Worksafe logo on the front page, are used to lodge claims in Victoria and complete all questions and authorisations except for those indicated as specific to NSW.

The following information will assist a person when completing the Employer Injury Claim Form. Select from the below list to view relevant help information for each section:

• 1. Employer’s  Details
• 2. Worker’s Details
• 3. Worker’s Employment Details
• 4. Worker’s Return To Work Details
• 5. Claim Confirmation Details
• 6. Worker’s Earning Details
• 7. Incident Details
• 8. Additional Information
• 9. Employer’s Declaration

 

1. Employer’s Details

The following information may assist in completing the Employer’s Details section of the form.

Accurate identification and contact details are essential for timely assessment and management of the claim including the following:

• Employer’s scheme registration number: Provide WorkSafe Employer Number which can generally be found on WorkSafe Premium Notices, Declaration of Rateable Remuneration, Invoices /Statements etc.
• Employer’s reference number (your reference): Optional information that you may provide your agent as your reference for the claim 
• Name and daytime contact number of the return to work coordinator (if any): Name and daytime telephone number of employer contact in relation to your injury management, return to work and claim management.

2. Worker’s Details

The following information may assist in completing the Worker's Details section of the form.

• Daytime contact phone number/s: Provide worker’s most appropriate daytime contact number, mobile, work and /or home.

3. Worker’s Employment Details

The following information may assist in completing the Worker's Employment Details section of the form.

• Street address of the worker’s usual workplace (plus suburb & postcode):  Address of worker’s normal workplace (employer home base for workers who also work on other sites).
• Workplace number for worker’s usual workplace: Provide WorkSafe Workplace Number which can generally be found on WorkSafe Premium Notices, Declaration of Rateable Remuneration, Invoices /Statements etc.

4. Worker’s Return To Work Details

The following information may assist in completing the Worker's Return To Work Details section of the form.

•  If the worker has returned to work, please provide the date: If the worker has returned to work provide the date of return. If they have not returned leave blank
  • What duties are they doing? Full or Suitable / Modified: If worker has returned to your pre - injury duties answer Full. If worker has returned to alternative duties or modified duties in their pre – injury job, answer Suitable / Modified.
  • How many hours do they work each week? Indicate the number of hours worked per week since returning to work.
• Have you provided the worker with a return to work plan, taking account the injury/condition? Please attach a copy of the return to work plan or agreement, or please explain why you have not provided a plan: More information regarding Return to Work Obligations and Return to Work Guide for Victorian Employers
• If the worker has not returned to work, do you know of any issues that would delay or prevent a return to work? If there are any issues that would delay or prevent a return to work please record in this section. If there are no issues answer NO.  If the worker has already returned to work leave blank 

5. Claim Confirmation Details

The following information may assist in completing the Claim Confirmation Details section of the form.

If you agree the injury is work-related, and believe that the details provided in sections 2 & 4 of the Worker’s Injury Claim Form are correct, you do not need to complete sections 6, 7 & 8. Otherwise please complete any relevant questions.  You MUST complete section 9

6. Worker’s Earning Details

The following information may assist in completing the Worker's Earning Details section of the form.

• How many standard hours did the worker work each week before being injured? “Standard hours" means the core hours the injured worker regularly works that are paid at a base rate or normal pay rate.
• Please provide details of any overtime or shift work - average weekly overtime, weekly shift allowance: Attach a detailed schedule of overtime and/or shift allowance worked over the prior 12 month period, or if the worker has worked for you less than 12 months, the period under your employ.

7. Incident Details

The following information may assist in completing the Incident Details section of the form.

Accurate details of the full extent of the worker’s injury and the causes of the injury are essential in managing the worker’s injury and return to work, and useful to help prevent further injuries.

• What is the worker’s injury/condition, and which parts of the body are effected? The worker’s WorkSafe Certificate of Capacity may assist you describing the injury.
• What happened and how was the worker injured? This question is asking for the direct cause of the worker’s injury. In other words the sudden event or change that turned what the worker was doing into the situation in which the worker was injured.
• What is the street address where the incident occurred? Be as specific as you can when describing the address at which the worker was injured. e.g. street number, name, suburb, postcode, level or floor (where applicable). This information can assist in preventing similar accidents happening.
• What date and time did the injury occur? If the injury was the result of a sudden event/accident complete the date and time in the space provided. If the injury/condition is a gradual onset injury, that is, an injury that has developed over time rather than from one incident, provide the date that the injury first came to your attention and provide a description under the previous question - What happened and how was the worker injured?
• What date and time did the worker first cease work? The date and time the worker ceased work as a result of this injury/condition lets us know the date from which compensation payments can be paid. If the worker did not cease work as a result of the injury print N/A in the space provided.
• Has the worker had a similar injury/condition or personal injury claim that relates to this injury/condition? Details should include the date and description of how the similar injury/condition occurred and associated claim numbers, if any.

8. Additional Information

The following information may assist in completing the Additional Information section of the form.

Provide any additional information you feel will assist in assessing the claim, managing the worker’s injury and return to work. If you believe you are not required to pay compensation as claimed by the worker include the reasons in this section.

9. Employer’s Declaration

The signature of your responsible representative to declare that the information provided on the form is true and correct is mandatory. If the declaration is not complete the form will be returned for signature.