Worker’s Injury Claim Form

As the worker you need to: For help completing this form or
• Answer all of the questions in Part A of this form using a dark blue for more information contact:
or black pen, except for question 7 which your employer will
• Your employer or the nominated Return to Work Coordinator
complete. The form may be returned to you if it is incomplete
at your workplace
• Sign the authority to release medical information and worker’s
• Your employer’s WorkSafe Agent - to find out who the Agent
declaration on page 5. The form cannot be accepted without
is, check the If you are injured poster or call the WorkSafe
your signature
Advisory Service
• Keep a copy of all documents for your records
• WorkSafe Advisory Service - the WorkSafe call centre:
• Notify your employer as soon as possible that you’ve been injured freecall 1800 136 089
at work, and complete the injury register at your workplace
• Your union, or Union Assist - a free service set up and run
• Report the accident to the police if your injury was the result of by the Victorian Trades Hall Council: (03) 9639 6144
a motor vehicle accident. Otherwise your claim may not be valid
• Give this form (when completed) to your employer as soon as
Information in your language
possible after being injured. If you have difficulty giving this claim For translated information and resources visit
to your employer, or your employer refuses to take receipt of the worksafe.vic.gov.au/choose-your-language, or
claim form, you can lodge it directly on the Agent or WorkSafe call 131 450 to speak to WorkSafe with an interpreter.
Victoria (WorkSafe) if the Agent is not known
Further information for workers - What your
• See your medical practitioner to obtain a WorkSafe Certificate
of Capacity (medical certificate) if you are unable to work and Agent will do
want to claim weekly payments, and give the original copy to The WorkSafe Agent will write to you and advise you if your claim
your employer along with this form. It is a good idea to check that is accepted.
all of the injuries or illnesses that you are claiming for on this form
A decision to accept or reject your claim will usually be made
are listed on the WorkSafe Certificate of Capacity
within 28 days from the date the Agent received your claim.
• Note that if your claim is accepted, WorkSafe can pay the
reasonable costs of medical and like expenses. However, this Provisional payments for a mental injury
may not mean payment of the full costs. In some cases there If your claim includes a mental injury, the Agent will also decide if
may be a gap between what the provider charges you and you are entitled to provisional payments, a decision that will
what WorkSafe can pay as reasonable costs. If you want usually be made within five business days of you providing your
to know the reasonable costs for a particular service, visit claim form to your employer. If you are entitled, the reasonable
the WorkSafe website at worksafe.vic.gov.au costs of medical treatment and services can be paid while we
• Read the statement on page 7 that explains how decide if the claim will be accepted. If your claim is accepted, we
your personal and health information will be collected and will continue to cover these costs in accordance with workers’
used and how your weekly payments will be calculated compensation legislation. If your claim is rejected, we will continue
if your claim is accepted. to cover these costs for up to 13 weeks.
To find out more about making a claim, and what support is
Getting back to work available to help you return to work, talk to your Agent, refer to the
• Talk with your employer to plan your return to work brochure Introducing WorkSafe, A guide for injured workers, or
visit the WorkSafe website at worksafe.vic.gov.au
• Talk to your medical practitioner or healthcare provider about
what parts of your work you could do and any limitations you have.
You can also encourage your medical practitioner or healthcare
provider to talk to your employer about your capacity for work and
any suitable duties that may be available
• Talk to the Agent about what support is available to help you
return to work and overcome your injury as quickly as possible.

FOR502/16/10.22
As the employer you need to:
• Complete and sign Part A (question 7) and Part B of this form
using a dark blue or black pen. Alternatively, you can download
the form as a PDF, complete, print and sign. Visit worksafe.vic.
gov.au/resources/workers-injury-claim-form
• Forward these documents within the timeframes below or you
may be financially penalised
• Confirm to the worker in writing that they have notified you of this
claim (you can do this by giving them a copy of this form when
signed and completed).

If the claim includes a mental injury If the claim is for a physical injury If the claim is for a physical injury
only and: only and:
• includes weekly payments; or • doesn’t include weekly payments;
Then within 3 business days of • is above the medical excess; or and
receiving the claim, you must • is expected to exceed the • is below the medical excess; and
forward to your Agent: medical excess; or • is not expected to exceed the
• the Worker’s Injury Claim Form • you are disputing liability medical excess; and
Part A (early notification) • you are not disputing liability

Then within 10 calendar days of

Also, within 10 calendar days of receiving the claim, you must Then within 120 calendar days of
receiving the claim, you must forward to your Agent: receiving the claim, you must
forward to your Agent: • the Worker’s Injury Claim Form forward to your Agent:
• the Worker’s Injury Claim Form Part B Parts A and B • the Worker’s Injury Claim Form
• any Certificates of Capacity • any Certificates of Capacity Parts A and B
• the Employer Injury Claim Report • the Employer Injury Claim Report
(optional) (optional)

If the claim is accepted: Further information for employers

• Pay your worker weekly payments if their claim is Claims with a mental injury – Early notification required
accepted and they have an entitlement
• If the claim includes a mental injury (with or without a physical
injury), to avoid financial penalties, you need to:
Getting your worker back to work
• Support your worker to plan their return to work (if required) • Forward Part A of this form (early notification) to your Agent,
including your completed and signed question 7, no later than
• Provide your worker with suitable employment when they three business days after receiving it from the worker, and
have a capacity to work
• Forward your completed and signed Part B of this form, and
• Provide your worker with pre-injury employment when they any WorkSafe Certificates of Capacity, to your Agent no later
have recovered and no longer have an incapacity for work than 10 calendar days after receiving Part A from the worker

• Appoint a Return to Work Coordinator who is competent • If the claimant is not your worker, this form must still be forwarded
to support the worker’s return to work. to your Agent. Please provide evidence of the claimant not being
your worker to your Agent, by attaching it to Part A of this form.
• WorkSafe also encourages employers to provide early
notification (Part A of this form) for physical injury claims.
• If you are a self-insurer, Parts A and B must be completed and
a determination about entitlement to provisional payments must
be made within 5 business days.

2
 This form can be used to lodge a workers’ compensation claim in Victoria
Complete this form using a dark blue or black pen. Alternatively, you can
download the form as a PDF, complete, print and sign. Visit worksafe.vic.gov.au/
resources/workers-injury-claim-form

2. Incident & worker’s injury details

Worker’s Injury Claim
Form Part A
Is your injury: A physical injury A mental injury

You can tick one or both options above.

As the worker, you need to complete questions

What is your injury/condition, and which parts of your
1 to 6 on Part A of this form.
body are affected?
As the employer, you need to complete:
• Part A question 7, and Raynauds phenomenon
• Part B question 8. Hands ie. fingers

1. Worker’s personal details What happened and how were you injured?

Blue & white fingers Brought on by pick-

Title Miss Family name Blundell packing frozen food in cold store freezers
Given names Maria
Other known or previous legal names e.g. Maiden name
What task/s were you doing when you were injured?

Directly Picking frozen goods off a rack onto a

Date of birth Gender
belt through a light picking system
04/07/1975
DD / MM / YYYY Male Female

Residential street address

What area of the worksite were you working in when
79 fairhaven boulevard you were injured?

Picking off the rack

Suburb State Postcode What is the street address where the incident occurred?

Cranbourne west VIC 3977 42 colemans road

Carrum downs 3201
Postal address for correspondence

Name of employer responsible for this workplace

Dawn
What are your daytime contact phone numbers? Which of the following incident circumstances apply?

Mobile Work Home While working at your usual workplace

0449749745 While working away from your usual workplace

Email address
During a meal-break or authorised recess at work
[email protected]
While away from work during a recess
Please read the information on “Communicating with you” on page 7 and indicate
below if you agree to WorkSafe sending you personal and health information relating
Travelling to or from work
to your claim via email and SMS.

I agree I do not agree A motor vehicle accident while you were working
(WorkSafe will communicate
with you via post) If your injury was the result of driving or using a motor vehicle or
the use of public transport, please provide the following details:
If you need an interpreter, what language do you speak?
The police station the accident was reported to
No
Do you have special communication needs because of disability?
N/A
e.g. Hearing or vision impairment Registration number/s of involved vehicles State
No N/A

PART A 3
Do you believe that your injury/condition was caused or Name and daytime phone number of employer contact
contributed to by a third party such as a manufacturer or supplier? e.g. Name of Return to Work Coordinator
Please give details if relevant
03 8796 5600
No
What is your usual occupation? What do you do?

High pace pick Packer

What was the date and time the injury/condition occurred?
Which of the following apply to you? (Please tick all relevant boxes)
Date Time AM PM
Full-time Part-time Casual Student
When did you first notice the injury/condition?
Apprentice Volunteer Contract Trainee
Early August
Agency Contractor Permanent Temporary
If you stopped work, what was the date and time? worker

Seasonal Jockey
Date Time AM PM

When did you report the injury/condition to your employer? Other

Early August When did you start working for this employer?

What is the name and position of the person you reported the July 2019
injury/condition to?
Please indicate if any of the following apply to you:
Jason - afternoon shift supervisor
A director of my employer’s company Yes No
Gretchen strauss - people and culture
business partner A partner in my employer’s company Yes No
If you did not report the injury/condition, or there was a delay,
please explain why A sole trader Yes No
N/A
A relative of my employer Yes No

Did you have any other employment at the time you were injured?
What are the names and daytime contact details of anyone who Please provide or attach the names of any other employers and their contact details,
and any relevant wage or payment records
witnessed the incident?

N/A No

4. Worker’s primary earning details

Have you previously had another injury/condition or personal injury Please complete these questions if you wish to claim for weekly payments

claim that relates to this injury/condition? How many standard hours did you work each week before
Please give details, including claim numbers
being injured? Exclude overtime
'N/A 34
What were your usual working hours?
For example, Monday to Friday, 8:30 am to 5:30 pm

3pm-11.30pm
3. Worker’s employment details What was your usual pre-tax hourly rate?*
Exclude overtime & shift allowances
Name of organisation paying your wages when you were injured
30.90000
Light and easy
What were your usual pre-tax weekly earnings?*
Street address of your usual workplace Exclude overtime & shift allowances
* Please provide copies of any recent payslips (if available)

42 Colemans rd $850-900
Please provide details of any overtime or shift work
Suburb State Postcode Weekly shift allowance: 4.63500
Carrum downs Vic 3201
Weekly overtime (hours): N/A

PART A 4
 5. Treatment & return to work details 7. Employer details
Please provide the name, clinic or hospital, and contact details of Employer to complete
any medical providers (including clinics or hospitals) that have This question is required to be completed on all claims
treated your injury
Claims with a mental injury – Early notification required
Dr Mark Overton If the worker has indicated they have a mental injury (question 2),
Our Medical you must complete and forward Part A of this form to your Agent
32/36 Remount west Cranbourne west within three business days of receiving it from the worker.
03 8375 8888 While we encourage you to forward Part B together with Part A,
If you have returned to work with your employer, what was the date? you can choose to forward Part B separately but you must
forward Part B no later than 10 calendar days after receiving
Currently have not returned Part A from the worker.
Are you forwarding Parts A and B together?*
What duties are you doing? Full Suitable/Modified
Yes
How many hours are you working each week?
If you tick this box: the claim determination timeframe
N/A of 28 days will commence upon the Agent receiving both
Part A and Part B from you.
Have you returned to work with a new employer? If you do not tick this box: You are required to forward
Please provide the name and contact details of the new employer
Part B within 10 calendar days of receiving Part A from
N/A your worker. The claim determination timeframe of 28
days will commence from the date the Agent receives
Part B from you.
If you have not returned to work, do you think that there are any Please tick below if you have attached the following evidence
issues that would delay or prevent you from returning to work? to this form. I have attached evidence of:
Currently have been sent home by employer (a) the worker not being my worker

(b) the claim being a duplicate claim

When did/will you give your employer this claim form? Please tick one or more where appropriate.
Lawyer will provide WorkSafe also encourages employers to provide early
notification for physical injury claims.
How did/will you give this claim form to your employer?
* If you are a self-insurer, you do not need to answer this question.
Hand delivery By post
When did you first receive the worker’s completed claim form?
When did/will you give your employer the first medical certificate?

22/1/2024
Date forwarded to Agent:
6. Authority to release medical information
Employer’s signature Date
and worker’s declaration
I have read the information provided in this form. I declare that the DD / MM / YYYY
Sign here
information that I have supplied in this form, and any attachments
to this form, is true and correct to the best of my knowledge. Name
I understand that the making of a false or misleading claim or false
and misleading statement in support of the claim is punishable
by law and that I may be prosecuted.
Position
I authorise and consent to any person who provides a medical
service or hospital service to me in connection with an injury/
condition to which this claim relates to provide upon request by the
workers’ compensation authority, my employer or insurer/claims Employer’s scheme registration number
e.g. WorkCover Employer, Policy, or Employer Registration Number
agent or any committee established under legislation to advise the
workers’ compensation authority, any information regarding the
service relevant to the claim. I understand that my authority has
effect and cannot be revoked for the duration of this claim or any
period where I am entitled to provisional payments.
Please note that there are penalties for providing false
or misleading information in relation to this claim.
Worker’s signature Date

Sign here 26/04/2024

DD / MM / YYYY

PART A 5
Worker’s Injury Claim
Form Part B
Part B is compulsory for all claims and must be completed by the Complete this form using a dark blue or black pen. Alternatively,
employer and forwarded to the Agent no later than 10 calendar you can download the form as a PDF, complete, print and sign.
days after receiving the worker’s completed Part A. Visit worksafe.vic.gov.au/resources/workers-injury-claim-form
If you as the employer do not forward these documents in time,
you may be financially penalised.
Employer requirements
If the claim includes a mental injury If the claim is for a physical injury If the claim is for a physical injury
only and: only and:
• includes weekly payments; or • doesn’t include weekly payments;
Then within 3 business days of • is above the medical excess; or and
receiving the claim, you must • is expected to exceed the • is below the medical excess; and
forward to your Agent: medical excess; or • is not expected to exceed the
• the Worker’s Injury Claim Form • you are disputing liability medical excess; and
Part A (early notification) • you are not disputing liability

Then within 10 calendar days of

Also, within 10 calendar days of receiving the claim, you must Then within 120 calendar days of
receiving the claim, you must forward to your Agent: receiving the claim, you must
forward to your Agent: • the Worker’s Injury Claim Form forward to your Agent:
• the Worker’s Injury Claim Form Part B Parts A and B • the Worker’s Injury Claim Form
• any Certificates of Capacity • any Certificates of Capacity Parts A and B
• the Employer Injury Claim Report • the Employer Injury Claim Report
(optional) (optional)

8. Additional employer details Employer’s Signature Date

Worker family name DD / MM / YYYY

Sign here

Name
Worker given names

Position
Worker date of birth

Employer’s scheme registration number

What is the claim number for this claim e.g. WorkCover Employer, Policy, or Employer Registration Number

(if known, for mental injury claims)?

Claim number

When did you first receive the worker’s medical certificate? Further information for employers -
Employer Injury Claim Report
The Employer Injury Claim Report is an official document you,
Date forwarded to Agent as the employer, should complete and send to your Agent.
It is a record of your details, your worker’s details, particulars
of the incident, and an opportunity for you to provide additional
Estimated cost of claim to date information, such as disputing liability.
WorkSafe encourages employers to complete this report.
This report should be provided to the Agent with Part B,
How many days have been lost? within 10 calendar days of you receiving the Worker’s Injury
Claim Form Part A. Please visit worksafe.vic.gov.au to
Days Hours download the report.

PART B 6
Workplace Injury Rehabilitation and Compensation Act 2013

Worker’s Injury Claim Form Communicating with you

WorkSafe may use your email address or mobile telephone
Collection of personal and health information number for any purpose for which you provide it, including to
to manage your claim* send you personal and health information relating to your claim.
Email and SMS are convenient and consistent methods of
In processing your claim, the Victorian WorkCover Authority
communication, but you should understand that they are not
(WorkSafe) and any WorkSafe Agent acting for WorkSafe in relation
completely secure and there is a risk that they could be intercepted,
to your claim may collect personal and health information about you.
read or modified by others or sent to an incorrect address. If you
WorkSafe and its Agents are required by law to ensure that all people
have any questions, or if you would like to update your contact
about whom they collect personal and health information are
details or change your preferences for how WorkSafe
provided with the following information:
communicates with you, please contact us via the “Contact us”
WorkSafe is a body corporate established under the Victorian page on the WorkSafe website: worksafe.vic.gov.au.
workers’ compensation legislation. Agents are appointed by
WorkSafe under that legislation to act on its behalf in managing WorkSafe’s policies for managing personal and health information
workers’ compensation policies and claims for compensation. are set out in its Privacy Policy, which is available from your nearest
WorkSafe office or at the WorkSafe website at worksafe.vic.gov.au.
Personal and health information about you is collected on this form
Information relating to your right to access your WorkSafe claim
and may also be collected during the processing, assessing and
information is also available at the website.
management of your claim. It may be collected from your current,
previous and future employers, other government agencies, credit (*References to ‘your claim’ include any provisional payments you
reporting agencies, health service providers and other persons who may be entitled to. If your employer is an approved self-insurer,
can provide information relevant to the claim. references to ‘WorkSafe’ and ‘Agent’ should be read as if they were
references to ‘self-insurer’ and ‘approved agent of a self-insurer’.)
Personal and health information about you may also be collected by
solicitors, private investigators, loss adjusters and other service
providers acting on behalf of WorkSafe or your employer’s Agent.
Calculating your entitlement to weekly payments
Personal and health information collected about you is used for the Weekly payments are calculated based on your pre-injury
purpose of processing, assessing and managing your claim and to average weekly earnings (PIAWE), generally in the 52 weeks
verify any evidence you may submit in support of the claim. The before your injury. If you have been with your employer for less
information may also be used for one or more of the purposes listed than 52 weeks, your PIAWE will be your average weekly earnings
in Victorian workers’ compensation legislation for the purposes of in the period of actual employment.
legal proceedings arising under that legislation, to assist with your What information your employer needs to provide about
rehabilitation and return to work and to assist WorkSafe and Agents your earnings
to better manage claims generally.
To enable the WorkSafe Agent to calculate your PIAWE, your
For the purposes of processing, assessing and managing your employer will need to provide details of the following payments
claim, WorkSafe and your employer’s Agent may disclose personal made to you in the past 52 weeks of your employment, or if that
and health information about you to each other and to the following was less than 52 weeks, in the period of your actual employment.
types of organisations:
• Base rate of pay
• Employees, contractors and agents of WorkSafe and Agents
• Overtime and shift allowances
• Your employers
• Piece rates, tally bonuses and commissions
• Solicitors, medical practitioners and other health service
providers, private investigators, loss adjusters and other service • Non-pecuniary benefits including residential accommodation,
providers acting on behalf of WorkSafe or the Agent in relation to use of a motor vehicle, payment of health insurance or
the claim payment of education fees

• The Workplace Injury Commission and Medical Panels • Any salary sacrifice arrangements

• Any committee established under legislation to advise WorkSafe Your employer will also need to tell the Agent if, in the 52 week
period before the injury, your earnings increased due to a
• A court or tribunal in the course of criminal proceedings or any promotion, or if they decreased due to you voluntarily reducing
proceedings under any of the Acts which WorkSafe administers your hours or changing the nature of your work with the employer.
• Any other person, organisation or government agency If your earnings include any other items not listed above, please
authorised by you, or by law, to obtain the information. discuss this with your Agent.

Collection of this information may be required by Victorian workers’

compensation legislation. If you do not provide any part or all of this
information, your claim may not be accepted or processed. You may
request access to personal and health information about you
collected by WorkSafe or your employer’s Agent by contacting your
employer’s Agent.

7
Further information
WorkSafe Agents
Agent contact details are all available at
worksafe.vic.gov.au/agents

WorkSafe Advisory Service

Advisory hours: Monday to Friday 7:30am - 6:30pm
Phone (03) 9641 1444
Toll-free 1800 136 089
Email [email protected]
24/7 Emergency 13 23 60
Website worksafe.vic.gov.au

Deaf, hearing or speech impaired

Helpdesk hours: Monday to Friday 8am - 6pm EST
National Relay Service 1800 555 660
SMS 0416 001 350
Email [email protected]

Information in your language

For translated information and resources visit
worksafe.vic.gov.au/choose-your-language, or
call 131 450 to speak to WorkSafe with an interpreter.