Employer Injury Claim Report
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Employer Injury Claim Report (PDF 1987kb)
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. This form is best completed electronically using Adobe Reader version 8.0 and above. If you wish to maintain an older version of Adobe on your computer, the best option is to print this claim form and fill it in manually.
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 required to pay an additional amount under section 108 of the Accident Compensation Act 1985(the Act) and/or a penalty, and any interest owing to the worker under section 114E of the Act.
How to complete the form
You may complete this claim form by:
- opening the document and typing in the information, following the prompts, and then printing it, or
- 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 WorkSafe Medical Certificate) to your WorkSafe Agent.
If you have any problems about the claim you should first talk to your WorkSafe Agent. If you are still not satisfied, telephone the WorkSafe Advisory Service on (03) 9641 1444 or freecall on 1800 136 089.
Where to send the form
Forward claims to your WorkSafe Agent. Alternatively, you may submit your form electronically.
