Worker's injury claim form (PDF version)

What it contains

The Worker's injury claim form has 2 parts.

Questions 1-6 of part A are for the worker to complete.

Question 7 of part A and all of part B are for employers to complete and forward to their agent to start the formal claims process.

You must complete this form if you wish to submit an injury claim.

Submitting a PDF form

If you are going to print and sign the form, make sure you print the form one-sided instead of double-sided.

The agent may return the form to you if it is incomplete.

How to complete the PDF form

1. Make sure you download it to your computer and fill it in using Adobe Reader. It may not save if you fill it in using your browser.
2. Complete questions 1-6 of the form.
3. Sign the authority to release medical information and worker's declaration in question 6. The form cannot be accepted without your signature.
4. Please keep a copy of all documents for your records.
5. After you’ve completed questions 1-6, give both parts of this form 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. If you are unsure who your agent is, check the 'If you are injured’ poster in your workplace. You can also send it directly to WorkSafe at [email protected].
6. Give the original copy of the certificate of capacity to your employer along with this form. Make sure you all of the injuries/conditions you're claiming for on this form are listed on the certificate of capacity.