Worker's injury claim form

What it contains

The Worker's injury claim form has 2 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.

Your responsibilities as a worker

1. Notify your employer as soon as possible that you've been injured at work and complete the injury register at your workplace.
2. If your injury was the result of a motor vehicle accident, report the accident to the police. Otherwise, your claim may not be valid.
3. See your medical practitioner to get a WorkSafe certificate of capacity (medical certificate) if you can't work and want to claim weekly payments. You'll need to upload a copy of the certificate of capacity when you fill out the form. Make sure that all of the injuries/conditions you're claiming for on this form are listed on the certificate of capacity.
4. Complete questions 1-6 in part A of this form and submit it to your employer in myWorkSafe. Your employer will then be sent a form online so they can complete part B. After your employer completes part B, they will send it to your WorkSafe agent to be assessed.

If you'd prefer, you can download the form as a PDF below and complete, print and sign it. Once you complete questions 1-6 in part A of the form, you will need to give it to your employer to complete question 7 and part B. They will then forward it to your WorkSafe agent.

If your claim includes a mental injury

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.

Payment information

1. If your claim is accepted, WorkSafe can pay the reasonable costs of medical treatment and services for your accepted injury/condition.
2. WorkSafe publishes fee schedules which indicate the amount WorkSafe will pay for each item of treatment under the Medicare Benefit Schedule. If you choose to access a health provider that charges a fee above the WorkSafe fee schedule, you will be out of pocket for the gap payment.
3. The statement in step 6 of the online form (and on page 7 of the PDF form) 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).

More information

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 between 7.30 am and 6.30 pm, Monday to Friday
• your union, or Union Assist - a free service set up and run by the Victorian Trades Hall Council, on 03 9639 6144

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