What it contains

The form workers must complete in order to lodge a claim.

If you need help completing this form 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
  • Union Assist - a free service set up and run by the Victorian Trades Hall Council, contactable on 03 9639 6144

As a worker 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 authority to release medical information and worker’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
  • Notify your employer as soon as possible that you’ve been injured at work, and complete the injury register at your workplace. You can also notify the Agent directly by sending them the early notification'copy of this form
  • 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 this form (when completed) 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
  • Note that if your claim is accepted, WorkSafe can pay the reasonable costs of medical and like expenses. However, this may not mean payment of the full costs. In some cases there may be a gap between what the provider charges you and what WorkSafe can pay as reasonable costs
  • Read the statement on the back of this 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).