Employer injury claim report

This report is an official document the employer should complete and send to their agent. It is a record of the employer’s details, the worker’s details, particulars of a workplace incident and an opportunity provide additional information.
Last updated

Jun 2021

Reading level

difficult

File type and size

PDF, 210.89 kB

Document length

6 pages

What it contains

The form employers should complete after a worker completes a worker's injury claim form. WorkSafe encourages employers to complete this form to provide additional information relating to a worker’s claim.

If you need help completing this form or if you're unsure what to do next, you can contact:

  • your WorkSafe agent
  • WorkSafe's advisory service on 1800 136 089
  • For translated information and resources, please call 131 450 to speak to WorkSafe with an interpreter.

What you need to do as an employer: Claims including a mental injury

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).

As the claim includes a mental injury, you have an Early Notification Requirement. This means that within 3 business days of receiving the claim from the worker, you must forward to your Agent:

  • the Worker's Injury Claim Form Part A with Section 7 completed by you

If you believe the claimant is not your worker, or that the claim is a duplicate claim, provide evidence of this to the Agent together with the Claim Form Part A

Within 10 calendar days of receiving the claim form from your worker, you must forward to your Agent:

  • Worker's Injury Claim Form Part B completed by you
  • injured worker's medical certificate (Certificate of Capacity)
  • an Employer Injury Claim Report completed by you (optional)
  • any other relevant documentation, e.g. invoices or receipts for medical expenses

There can be penalties for failing to meet these timeframes.

Note: employer early notification obligations commence on, and provisional payments are only available for claims made on or after, 1 July 2021.

What you need to do as an employer: Claims with a physical injury/illness only

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 is for a physical injury only, with no mental injury component, you need to forward to your Agent within 10 calendar days of receiving the claim from the worker:

  • the Worker's Injury Claim Form Parts A and B, with the employer questions completed by you
  • injured worker's medical certificate (Certificate of Capacity)
  • an Employer Injury Claim Report completed by you (optional)
  • any other relevant documentation, e.g. invoices or receipts for medical expenses

There can be penalties for failing to meet these timeframes.

After forwarding the claim:

  • 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.

Completing the Employer Injury Claim Report:

  • Complete this form using a dark blue or black pen. The report 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.
  • Please keep a copy of all documents for your records.

Important: Please download this PDF to your computer. You can fill it in using Adobe Reader but it will not save if you attempt to fill it in using your web browser.

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