Employer injury claim report (PDF version)

What it contains

The Employer's injury claim report is:

• a record of the employer's details
• a record of the worker's details
• a record of particulars of a workplace incident
• an opportunity provide additional information, such as disputing liability.

Submitting a PDF report

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.

If you are going to print and sign the report, make sure you:

• print the form one-sided instead of double-sided
• use a dark blue or black pen
• sign the employer's declaration at the end of the form
• keep a copy of all documents for your records.

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