Worker's injury claim form

This form is for injured workers to fill out and submit a work-related injury claim.


What it contains

The worker's 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 forward to their agent to start the formal claims process. Workers must complete this form if they wish to submit 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
  • WorkSafe Advisory on 1800 136 089
  • your union, or Union Assist - a free service set up and run by the Victorian Trades Hall Council, 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 support is available to help you in your recovery and return to work, we encourage you to talk your health care professional. You can also refer to the brochure 'Introducing WorkSafe, a guide for injured workers' which you can get sent to you by calling WorkSafe Advisory.

Submitting a claim form online

You can also submit your claim using our online claim form process. Simply log in or create a myWorkSafe account and select 'Start new claim'.

As a worker you need to:

  • Complete questions 1-6 in Part A of this form using a dark blue or black pen. You can also 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. You don’t 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 in 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 accept the claim form, you can send it directly to the employer’s agent or to WorkSafe if the agent is not known.
  • See your medical practitioner to obtain a WorkSafe certificate of capacity (medical certificate) if you can't work and want to claim weekly payments, and give the original copy to your employer along with this form. Make sure you check that all of the injuries/conditions you're claiming for on this form are listed on the 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're 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 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/condition.
  • 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 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.