Worker's injury claim form

This form is for injured workers to fill out to lodge a work-related injury claim.
Last updated

Jun 2021

Reading level

difficult

File type and size

PDF, 285.24 kB

Document length

8 pages

What it contains

The Worker Injury Claim Form has two parts. Part A provides early notification of a claim and triggers the process for employers to complete and agents to consider entitlement to provisional payments.

Part B is for employers to complete their details and submit to their agent to start the formal claims process. Workers must complete this form if they wish to lodge an injury claim.

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

  • your employer or the nominated Return to Work Coordinator at your workplace
  • your employer's WorkSafe Agent - to find out who the agent is check the If you are injured poster' in your workplace or call WorkSafe's advisory service
  • WorkSafe's advisory service on 1800 136 089
  • your union, or Union Assist - a free service set up and run by the Victorian Trades Hall Council, contactable on 03 9639 6144
  • For translated information and resources, call 131 450 to speak to WorkSafe with an interpreter or visit our website.
  • To find out more about making a claim and what supports are available to help you in your recovery and return to work, we encourage you to talk your Health Care Professional or refer to the brochure 'Introducing WorkSafe, a guide for injured workers' which can be sent to you by calling the WorkSafe Advisory service.

As a worker you need to:

  • Complete questions 1-6 in Part A of this form using a dark blue or black pen. Alternatively, you can download this form as a PDF, complete, print and sign. Please print the form one-sided instead of double sided. The form may be returned to you if it is incomplete. Note that you do not need to complete Part B of the form, this is for your employer to complete.
  • Sign the authority to release medical information and worker's declaration at question 6. The form cannot be accepted without your signature.
  • Please keep a copy of all documents for your records.
  • Notify your employer as soon as possible that you've been injured at work, and complete the injury register at your workplace.
  • Report the accident to the police if your injury was the result of a motor vehicle accident. Otherwise, your claim may not be valid.
  • Give both parts of this form (after you have completed Part A) to your employer as soon as possible after being injured. If you have difficulty giving this claim to your employer, or your employer refuses to take receipt of the claim form, you can send it directly to the agent or WorkSafe if the agent is not known.
  • See your medical practitioner to obtain a WorkSafe Certificate of Capacity (medical certificate) if you are unable to work and want to claim weekly payments, and give the original copy to your employer along with this form. It is a good idea to check that all of the injuries or illnesses that you are claiming for on this form are listed on the WorkSafe Certificate of Capacity.
  • If your claim includes a mental injury, you may be entitled to provisional payments. This means that the Agent will be able to pay for reasonable treatment costs of your claimed mental injury while a decision on the claim is being made. The Agent will let you know whether you are entitled to provisional payments, usually within 5 business days of you submitting your claim. If your claim is accepted, the Agent will continue to cover these costs in accordance with workers' compensation legislation. If your claim is rejected, the Agent will continue to cover these costs for up to 13 weeks.
  • If your claim is accepted, WorkSafe can pay the reasonable costs of medical treatment and services  for your accepted injury/injuries.
  • WorkSafe publishes a fee schedule which indicates the amount WorkSafe will pay for each item of treatment under the Medicare Benefit Schedule (MBS). If a worker or volunteer chooses to access a health provider that charges a fee above the WorkSafe fee schedule, they will be out of pocket for the gap payment.
  • Read the statement on page 7 of the interactive form that explains how your personal and health information will be collected and used and how your weekly payments will be calculated (if your claim is accepted).

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

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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