Worker’s injury claim form

For help completing this form or for more Getting back to work
information contact: • Talk with your employer to plan your return to work
• Talk to your medical practitioner or healthcare provider
• Your employer or the nominated Return to Work Coordinator
about what parts of your work you could do and any limitations
at your workplace
you have. You can also encourage your medical practitioner
• Your employer’s WorkSafe Victoria (WorkSafe) Agent - to find
or healthcare provider to talk to your employer about your
out who the Agent is check the If you are injured poster or call
capacity for work and any suitable duties that may be available
the WorkSafe Advisory Service: freecall 1800 136 089
• Talk to the Agent about what support is available to help you
• WorkSafe Advisory Service - the WorkSafe call centre:
return to work and overcome your injury as quickly as possible
freecall 1800 136 089
• Your union
• Union Assist - a free service set up and run by the Victorian Your employer’s responsibilities:
Trades Hall Council: (03) 9639 6144 • To confirm to you in writing that you notified them of this claim
(they can do this by giving you a copy of this form when signed
As the worker you need to: and completed)
• If you are claiming weekly payments, they must send the
• Answer all of the questions on this form. Carefully complete this
completed form and any WorkSafe Certificates of Capacity
form using a dark blue or black pen. The form may be returned
(medical certificates) to the Agent as soon as possible, but
to you if it is incomplete
no later than 10 days after receiving them from you - or they
• Sign the authority to release medical information and worker’s
may be financially penalised
declaration at the end of this form. The form cannot be accepted
• To pay you weekly payments if your claim is accepted and
without your signature
you have an entitlement
• Keep a copy of all documents for your records
• To work with you to plan your return to work (if required)
• Notify your employer as soon as possible that you’ve been injured
• To provide you with suitable employment when you have
at work, and complete the injury register at your workplace. You
a capacity to work
can also notify the Agent directly by sending them the “early
• To provide you with pre-injury employment when you have
notification” copy of this form
recovered and no longer have an incapacity for work
• Report the accident to the police if your injury was the result of
• To appoint a return to work coordinator who is competent
a motor vehicle accident. Otherwise your claim may not be valid
to support your return to work.
• Give this form (when completed) to your employer as soon as
possible after being injured. If you have difficulty giving this claim
Please note that there are penalties for providing false
to your employer, or your employer refuses to take receipt of the
or misleading information in relation to this claim.
claim form, you can send it directly to the Agent or WorkSafe if the
Agent is not known
The WorkSafe Agent will write to you and advise you if your
• See your medical practitioner to obtain a WorkSafe Certificate
claim is accepted.
of Capacity (medical certificate) if you are unable to work and
want to claim weekly payments, and give the original copy to your A decision to accept or reject your claim will usually be made
employer along with this form. It is a good idea to check that all within 28 days from the Agent received date.
of the injuries or illnesses that you are claiming for on this form
To find out more about making a claim, and what support is available
are listed on the WorkSafe Certificate of Capacity
to help you return to work, talk to the Agent, refer to the brochure
• Note that if your claim is accepted, WorkSafe can pay the
Introducing WorkSafe, a guide for injured workers, or visit the
reasonable costs of medical and like expenses. However, this
WorkSafe website at worksafe.vic.gov.au.
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. If you want to know the
reasonable costs for a particular service, visit the WorkSafe
website at worksafe.vic.gov.au.
• 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).

FOR502/13/03.20
 This form can be used to lodge a Workers’ Compensation Claim
in New South Wales, Queensland or Victoria
Please complete form using a dark blue or black pen

Worker’s injury claim form

Please indicate in which State you want to lodge this claim: If you need an interpreter, what language do you speak?

NSW QLD VIC

Do you have special communication needs because of disability?
eg. Hearing or vision impairment

1. Worker’s personal details

Title Family name
*These questions are required for NSW claims
Mr Joshi Do you support a partner?*

Given names Yes No

Shreyas If yes, what were their average gross weekly earnings

over 3 months?*
Other known or previous legal names eg. Maiden name

Do you support any children under the age of 18,

Date of birth Gender or full-time students?*

24/10/1990 Male Female Yes No

Residential street address If yes, please provide the date of birth for each*

29 Mclaurin Road

Suburb State Postcode 2. Incident & worker’s injury details

Carnegie VIC 3163 What is your injury/condition, and which parts of your body
are affected?
Postal address for correspondence
Right Eye Swelling
29 Mclaurin Road Carnegie Vic 3163

What happened and how were you injured?

What are your daytime contact phone numbers?
While inspecting the recycle bin for MRA consulting
Mobile Work Home Dust particles went into the eye as soon as I opened the
bin and the right eye started swelling
0401552227

Email address

[email protected]
What task/s were you doing when you were injured?
*This question is required for Victorian claims
Please read the information on “Communicating with You” at the end of this form and Waste Management Audit
indicate below if you agree to WorkSafe sending you personal and health information
relating to your claim via email and SMS.*

I agree
What area of the worksite were you working in when you
I do not agree were injured?
(WorkSafe will communicate with you via post) Altona North Hobsons Bay City Council

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What is the street address where the incident occurred? When did you report the injury/condition to your employer?
35 Beevers Street Immediately as it happened I reported it to the manager

What is the name and position of the person you reported the
injury/condition to?
Suburb State Postcode
Claire Mahendradatta Senior Environmental Consultant
Altona North VIC 3025

Name of employer responsible for this workplace

If you did not report the injury/condition, or there was a delay,
MRA Consulting please explain why

Which of the following incident circumstances apply?

While working at your usual workplace

While working away from your usual workplace What are the names and daytime contact details of anyone who
witnessed the incident?
During a meal-break or authorised recess at work
Claire Mahendradatta 0403886284
While away from work during a recess

Travelling to or from work*

A motor vehicle accident while you were working*

*For NSW incidents a journey claim form must also be completed Have you previously had another injury/condition or personal injury
claim that relates to this injury/condition?
If your injury was the result of driving or using a motor vehicle or the
Please give details, including claim numbers
use of public transport, please provide the following details:

The police station the accident was reported to

Registration number/s of involved vehicles State

3. Worker’s employment details
Name of organisation paying your wages when you were injured
Do you believe that your injury/condition was caused or
contributed to by a third party such as a manufacturer or supplier? MRA Consulting
Please give details if relevant
Street address of your usual workplace
Henry Lawson, Building, 408/19 Roseby St,

What was the date and time the injury/condition occurred?

Suburb State Postcode
Date Time AM PM
Drummoyne Drummoyne 2047
10/02/2021 1.36
Name and daytime contact number of employer contact
When did you first notice the injury/condition? eg. Name of return to work coordinator

Something went in my eye so after 5 minutes it started swelling Claire Mahendradatta 0403886284

If you stopped work, what was the date and time? What is your usual occupation? What do you do?
Date Time AM PM Waste Management Audit
10/02/2021 1.42

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Which of the following apply to you? Please provide details of any overtime or shift work
(Please tick all relevant boxes)
Weekly shift allowance
Full-time Part-time Casual Student

Apprentice Volunteer Contract Trainee

Weekly overtime
Agency worker Contractor Permanent Temporary
hrs
Seasonal Jockey

Other

When did you start working for this employer? 5. Treatment & return to work details

08/02/2021 * This question is required for NSW claims

Who is your nominated treating doctor?*
Please indicate if any of the following apply to you:
Name Phone
A director of my employer’s Yes No
company

A partner in my employer’s Yes No Please provide the name, clinic or hospital, and contact details of
company any medical providers (including Clinics or Hospitals) that have
treated your injury
A sole trader Yes No
Footscray Hospital
A relative of my employer Yes No

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

If you have returned to work with your employer, what was the date?

11/02/2021

What duties are you doing? Full Suitable/Modified

4. Worker’s primary earning details
How many hours are you working?
Please complete this section if you wish to claim for weekly payments

How many standard hours did you work each week before 32 hours
being injured? Exclude overtime
Have you returned to work with a new employer?
Please provide the name and contact details of the new employer
Started a day ago so I worked only 8 hours before injury happened
No
What were your usual working hours?
For example, Monday to Friday, 8.30 am to 5.30 pm

MIdnight till 8 am
If you have not returned to work, do you think that there are any
issues that would delay or prevent you from returning to work?
What was your usual pre-tax hourly rate?*
Exclude overtime & shift allowances

37.32

What were your usual pre-tax weekly earnings?* When did/will you give your employer this claim form?
Exclude overtime & shift allowances
* Please provide copies of any recent payslips (if available) 25/02/2021

How did/will you give this claim form to your employer?

Hand delivery By post

When did/will you give your employer the first medical certificate?

10/02/2021

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 6. Authority to release medical information 7. Employer lodgement details
and worker’s declaration
When did the employer first receive the worker’s completed claim
I have read the information provided in this form. I declare that the information that form?
I have supplied in this form, and any attachments to this form, is true and correct to
the best of my knowledge. 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
When did the employer first receive the worker’s medical
I may be prosecuted.
certificate?
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 agent
*This question is required for Victorian claims
or any committee established under legislation to advise the workers’ compensation
Date claim form forwarded to Agent*
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.

Worker’s signature Date Estimated cost of claim to date

Shreyas Joshi 24/02/2021

* This declaration is also required for NSW claims How many days have been lost?
I authorise and consent to the collection, disclosure and release of any personal and
Days Hours
health information in connection with an injury/condition to which the claim relates
by the workers’ compensation authority, my employer or insurer/claims agent to each
Employer’s signature Date
other, or to any person who provides a medical service or hospital service to me in
connection with an injury/condition to which this claim relates. I understand that if this
claim results in my receiving weekly compensation payments, I am required to notify
whomever is paying my benefits if I commence employment with some other person Name
or in my own business, or of any change in my employment that affects my earnings,
and that failure to do so is an offence. I consent to the State Insurer Regulatory Authority
of NSW using the information collected in connection with my claim for the purposes
Position
of research about workers compensation, workplace injury management and
occupational health and safety.

Worker’s Signature Date Employer’s scheme registration number

eg. WorkCover Employer, Policy, or Employer Registration Number

5
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 send
to manage your claim* you personal and health information relating to your claim. Email
In processing your claim, the Victorian WorkCover Authority and SMS are convenient and consistent methods of communication,
(WorkSafe) and any WorkSafe Agent acting for WorkSafe in relation but you should understand that they are not completely secure
to your claim may collect personal and health information about you. and there is a risk that they could be intercepted, read or modified
WorkSafe and its Agents are required by law to ensure that all people by others or sent to an incorrect address. If you have any questions,
about whom they collect personal and health information are or if you would like to update your contact details or change your
provided with the following information: preferences for how WorkSafe communicates with you, please
contact us via the “Contact us” page on the WorkSafe website:
WorkSafe is a body corporate established under the Victorian
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 (*If your injury employer is an approved self-insurer, references to
reporting agencies, health service providers and other persons who ‘WorkSafe’ and ‘Agent’ should be read as if they were references to
can provide information relevant to the claim. ‘self-insurer’ and ‘approved agent of a self-insurer’.)

Personal and health information about you may also be collected by Calculating your entitlement to weekly payments
solicitors, private investigators, loss adjusters and other service
Weekly payments are calculated based on your pre-injury average
providers acting on behalf of WorkSafe or your employer’s Agent.
weekly earnings (PIAWE), generally in the 52 weeks before your
Personal and health information collected about you is used for the
injury. If you have been with your employer for less than 52 weeks,
purpose of processing, assessing and managing your claim and to
your PIAWE will be your average weekly earnings in the period of
verify any evidence you may submit in support of the claim. The
actual employment.
information may also be used for one or more of the purposes listed
in Victorian workers compensation legislation for the purposes of What information your employer needs to provide about
legal proceedings arising under that legislation, to assist with your your earnings
rehabilitation and return to work and to assist WorkSafe and Agents To enable the WorkSafe Agent to calculate your PIAWE, your
to better manage claims generally. employer will need to provide details of the following payments
For the purposes of processing, assessing and managing your made to you in the past 52 weeks of your employment, or if that
claim, WorkSafe and your employer’s Agent may disclose personal was less than 52 weeks, in the period of your actual employment.
and health information about you to each other and to the following • Base rate of pay
types of organisations: • Overtime and shift allowances
• employees, contractors and agents of WorkSafe and Agents • Piece rates, tally bonuses and commissions
• your employers • Non-pecuniary benefits including residential accommodation,
• solicitors, medical practitioners and other health service use of a motor vehicle, payment of health insurance or payment
providers, private investigators, loss adjusters and other service of education fees
providers acting on behalf of WorkSafe or the Agent • Any salary sacrifice arrangements
in relation to the claim Your employer will also need to tell the Agent if, in the 52 week
• the Accident Compensation Conciliation Service period before the injury, your earnings increased due to a promotion,
and Medical Panels or if they decreased due to you voluntarily reducing your hours
• any committee established under legislation to advise WorkSafe or changing the nature of your work with the employer.
• a court or tribunal in the course of criminal proceedings or any
proceedings under any of the Acts which WorkSafe administers If your earnings include any other items not listed above, please
• any other person, organisation or government agency authorised discuss this with your Agent.
by you, or by law, to obtain the information.
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.