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What it contains

The form employers must complete after a worker completes a worker's injury claim form.

If you need help completing this form you can contact:

  • Your WorkSafe agent
  • WorkSafe's advisory service on 1800 136 089

As an employer you need to:

  • Answer all of the questions on this form. Carefully complete this form USING A DARK BLUE or BLACK PEN. The form may be returned to you if it is incomplete
  • Sign the employer’s declaration at the end of this form. The form cannot be accepted without your signature
  • Keep a copy of all documents for your records
  • Confirm with your worker in writing that you’ve been notified of this claim (you can do this by giving them a copy of the Worker’s Injury Claim Form when signed)
  • If the claim includes weekly payments, send this completed form, the completed Worker’s Injury Claim Form, and any WorkSafe Certificate of Capacity (medical certificates) to your Agent as soon as possible, but no later than 10 days after receiving them from your worker - or you may be financially penalised
  • If the worker has an entitlement to compensation and the claim is accepted, pay the worker weekly payments
  • Pay the worker’s initial medical and treatment expenses, up to the level specified by your WorkSafe policy. If this threshold is exceeded, forward this report, the claim form, copies of accounts paid, and any unpaid accounts to your Agent within 10 days.