SAMPLE WORKCOVER EMPLOYER S CLAIM REPORT

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1 WORKCOVER EMPLOYER S CLAIM REPORT Please read these notes carefully before completing this form. When to use this form This form must be completed by the employer when you receive any of the following claims: a Worker s Claim Form for weekly payments for time loss a Worker s Claim Form for medical and like expenses which exceeds the employer excess a Dependant s Claim for Compensation Form. FILLING OUT THE FORM Complete all pages of this form. Use a ball point pen and print clearly. If there is insufficient space for answering any questions on the form, please attach additional notes. Sign the declaration on the form in the presence of a witness who is 18 years or older and who is not a relative. For a worker to claim an entitlement to overtime and/or shift allowance, the worker must have performed overtime or shift work for you at any time during the 12 months before the injury and it is likely that they would have worked overtime or shift work at some time in the next 26 weeks if not for the injury. If applicable, please attach a detailed schedule of overtime and/or shift allowance worked over the prior 12 month period, or if the worker has worked for you less than 12 months, the period under your employ. REPORTING OF INJURY/CONDITION If a worker suffers a work-related injury or condition, he or she (or someone else if the worker is unable to) must report it to you, in writing, within 30 days of becoming aware of it. The worker can notify you by filling in a Register of Injuries that you must keep at every workplace, or he/she can give notice in other written form. You must then let the worker know, in writing, that you have been notified of the injury or illness. If the injury or condition is serious or results in death, or could have resulted in a serious injury or death, you must notify WorkCover immediately on You must also complete and send an Incident tification Form to WorkCover within 48 hours. CLAIM RECEIVED Upon receipt of a completed WorkCover Worker s Claim Form or Dependant s Claim for Compensation, you must do the following: sign and date the form acknowledge receipt of the form in writing. This can be done by giving the worker/dependant a copy of the signed Claim Form complete an Employer s Claim Report. It is against the law to refuse receipt of a Worker s Claim Form or dismiss a worker for making a WorkCover claim. You should also keep a copy of the Worker s Claim Form or Dependant s Claim for Compensation, along with a copy of the Employer s Claim Report - all carbon copies are labelled as to who receives which copy. If the worker needs time off work for the injury/condition, he/she must give you a WorkCover Certificate of Capacity signed by a medical practitioner. Certificates of Capacity have a declaration on the back for the worker to indicate whether they have been working or not. The declaration does not need to be completed for the first certificate you receive from the worker. If the worker gives you more than one certificate make sure they complete the declaration for the ongoing certificates. After giving you a claim for weekly payments, the worker can also lodge a copy of the claim form (i.e. Early tification Form) and a copy of the Certificate/s of Capacity on the VWA or your VWA agent. Even if the worker chooses to notify the VWA agent of their claim you must still forward the originals of all documents to your VWA agent within 10 days of receiving them from the worker. EMPLOYER EXCESS If the claim is accepted by either yourself or your VWA agent, you must pay the first 10 days off work and relevant medical and like expenses. This is called the employer excess. (Due to indexation being applied at 1 July each year, please contact your VWA agent for the current excess limit for medical and like expenses). This excess applies unless you have taken up the Buy-out Option as part of your Workplace Injury Insurance premium. FORWARDING CLAIMS TO YOUR VWA AGENT You must forward to your VWA agent within 10 days any of the following: a claim for weekly payments; a claim for medical and like expenses (over the employer excess); Dependant s Claim for Compensation. Documentation to be forwarded includes: the original copy of the Worker s Claim Form or Dependant s Claim for Compensation the original completed Employer s Claim Report the worker s completed WorkCover Certificate of Capacity, signed by a doctor, if the claim involves time off work a copy of the worker s written notification of injury (either copy of entry in the register of injuries or other written form). If you fail to forward a claim and all documents on time, you may be required to pay a penalty and/or any interest owing to the worker. If you fail to forward a claim for weekly payments within the legislative timeframes, you may be required to pay, further to the employer excess, an additional excess which consists of weekly payments commencing the 11th day of incapacity and ceasing on the date the VWA agent receives the claim forms from you. If the claim is for medical and like expenses only and within your employer excess (termed a Minor Claim) make all payments, complete the Completion by employer - if claim is under excess section of the Worker s Claim Form and forward the Worker s Claim form to your VWA agent, within 14 calendar days of the end of the quarter in which you receive the claim. DETERMINING LIABILITY Your VWA agent must tell you and the worker in writing if the claim for weekly payments is accepted or not. This must be done within 28 days of the VWA agent receiving the claim form and WorkCover Certificate/s of Capacity from you. If the worker lodges an Early tification Form on your VWA agent, liability must be decided within: 28 days of the VWA agent receiving the claim form and documentation from you, if forwarded within 10 days; or 39 days of the VWA agent receiving the Early tification Form from the worker, if you forward the claim form and documentation outside the legislative timeframe of 10 days (see details above regarding penalty for late lodgement). NOTE: If you forward a claim for weekly payments to your VWA agent and it is received 39 days or more from when the worker served the claim on you, the claim will be deemed accepted upon receipt. If the claim is for medical and like expenses only and over your employer excess, your VWA agent has 60 days to advise you and the worker in writing if the claim is accepted or not. To find out more about WorkCover, visit our website at or contact your VWA agent. If you have any problems completing this claim form or with the acceptance or management of this claim, you should first talk to your VWA agent. If you are still not satisfied, or you do not know who your VWA agent is, telephone the WorkCover Advisory Service on (03) or, outside the metropolitan area, toll free on

2 ACCIDENT COMPENSATION ACT 1985 WORKCOVER EMPLOYER S CLAIM REPORT Name of employer 13) Name and position of person to whom injury/condition was reported Australian Business Number WorkCover Employer Number WorkCover Workplace Number Head office street address (PO Box number not acceptable) Address for correspondence (if different from above) 14) Has the worker entered the claimed injury/condition into the register of injuries? (go to 15) Yes (You must keep a register of injuries or injury report book. Penalty for failing to do so is up to 2,000.) Please attach a copy of the worker s written notification of injury and a copy of your written acknowledgement to worker. 15) Did anyone witness the injury/condition occurring? (go to 16) Yes If yes, name and address of witness 1 1) Worker s family name If yes, name and address of witness 2 Worker s given name/s 2) Occupation of worker (please describe fully, eg electrical fitter) 3) worker commenced employment with you 4) Type of employment (eg full time, part time, casual, seasonal) 5) Is the worker an apprentice? 6) Is the worker a direct employee? Yes (Go to 7) If no, explain relationship (eg contractor) 7) Give name and position title of worker s direct supervisor or manager at the time of injury INJURY OR CONDITION DETAILS 8) of injury/condition Time of injury/condition : am/pm 9) What date did the worker Time ceased work cease to work as a result as a result of of the injury/condition injury/condition : am/pm 10) Describe what you understand the worker s injury/condition to be 11) Describe how you understand the worker s injury/condition happened (ie hit head on cabin of forklift truck, cut knee when landing on ground, inhaled toxic fumes) 12) Do you know whether the worker has had a previous claim for this injury/condition? (go to 13) Yes 16) Address where injury/condition occurred 17) Is the location where the worker was injured one of your workplaces? Yes (go to 19) 18) Was this location controlled by another employer? (go to 19) If yes, name of employer who controlled this workplace 19) Is this the worker s usual workplace? Yes (go to 20) If no, address of worker s usual workplace 20) Business activity of workplace where worker was injured 21) State whether this workplace is a temporary or permanent worksite 22) Do you believe the worker s injury/condition was caused/ contributed by a third party such as a manufacturer/supplier? (eg faulty design of machinery, insufficient labelling of hazardous substances, negligent driving by third party) (go to 23) Yes If yes, give details 23) Do you believe the injury arose as a result of the worker s: violation of any statutory or other regulation? misconduct or breach of safety/work standards? If yes, claim number or date of injury

3 any other circumstances of which WorkCover should be aware? If no to all of the above, go to 24 If yes to any of the above, give details 36) Have you offered the worker a suitable job taking into account his/her injury/condition? Yes If yes, describe the job If no, give reasons why not PRE-INJURY AVERAGE WEEKLY EARNINGS DETAILS 24) Worker s total number of average ordinary hours worked per week prior to injury/condition (excluding overtime) 25) Worker s hourly rate (excluding overtime and allowances) 26) Pre-injury average weekly earnings at time of injury (excluding overtime and allowances) 27) Does the worker work Overtime? Shiftwork? 28) Weekly overtime Weekly shift allowance amount If applicable, please attach a detailed schedule of overtime and/or shift allowance worked over the prior 12 month period, or if the worker has worked for you less than 12 months, the period under your employ. 29) Gross weekly wage over the 3 years prior to injury including overtime and allowances 1 year prior 2 years prior 3 years prior 30) Has the worker returned to work? (go to 35) Yes If yes, date returned to work Time returned to work : am/pm Total number of days lost days 31) Is this a full return to work? (This means a return to full pre-injury duties for full pre-injury hours) Yes (go to 37) If no, give reasons 32) Total hours worker is working per week 33) Worker s hourly rate 34) Worker s gross weekly wage excluding overtime and allowances Weekly overtime Weekly shift allowance 35) If the worker has not returned to work, have you contacted the worker? the worker s treating doctor? (You must offer suitable employment within 12 months of injury as soon as the worker is able to return to work. Penalty for failing to do so is up to 25,000.) 37) Name of occupational rehabilitation provider (if involved) 38) Person to contact at your workplace regarding this claim 39) Position of contact person 40) Contact person telephone Contact person fax 41) address 42) Have you taken up the Buy-out option? 43) Have you completed an Incident tification Form? (please attach a copy) 44) Worker s Claim Form received by you 45) WorkCover Certificate of Capacity received by you 46) If there are any reasons why you believe you are not required to pay compensation as claimed by the worker, please give details EMPLOYER DECLARATION I declare that all of the information provided on this form is, to the best of my knowledge, true and correct. I am aware that to provide any false or misleading information in connection with this claim may be punishable by law. Signature of employer Signature of witness (witness may be any person 18 years or over who is not a relative) Under the authority signed by the claimant, medical information may only be obtained by a person responsible for administering or conciliating the claim. This information may only be used in respect of a matter or for a purpose arising under the Accident Compensation Act 1985 or the Accident Compensation (WorkCover Insurance) Act Unauthorised use of this information can result in a fine of up to 10,000. FOR589/04/07.05 ORIGINAL

4 ACCIDENT COMPENSATION ACT 1985 WORKCOVER EMPLOYER S CLAIM REPORT Name of employer 13) Name and position of person to whom injury/condition was reported Australian Business Number WorkCover Employer Number WorkCover Workplace Number Head office street address (PO Box number not acceptable) Address for correspondence (if different from above) 14) Has the worker entered the claimed injury/condition into the register of injuries? (go to 15) Yes (You must keep a register of injuries or injury report book. Penalty for failing to do so is up to 2,000.) Please attach a copy of the worker s written notification of injury and a copy of your written acknowledgement to worker. 15) Did anyone witness the injury/condition occurring? (go to 16) Yes If yes, name and address of witness 1 1) Worker s family name If yes, name and address of witness 2 Worker s given name/s 2) Occupation of worker (please describe fully, eg electrical fitter) 3) worker commenced employment with you 4) Type of employment (eg full time, part time, casual, seasonal) 5) Is the worker an apprentice? 6) Is the worker a direct employee? Yes (Go to 7) If no, explain relationship (eg contractor) 7) Give name and position title of worker s direct supervisor or manager at the time of injury INJURY OR CONDITION DETAILS 8) of injury/condition Time of injury/condition : am/pm 9) What date did the worker Time ceased work cease to work as a result as a result of of the injury/condition injury/condition : am/pm 10) Describe what you understand the worker s injury/condition to be 11) Describe how you understand the worker s injury/condition happened (ie hit head on cabin of forklift truck, cut knee when landing on ground, inhaled toxic fumes) 12) Do you know whether the worker has had a previous claim for this injury/condition? (go to 13) Yes 16) Address where injury/condition occurred 17) Is the location where the worker was injured one of your workplaces? Yes (go to 19) 18) Was this location controlled by another employer? (go to 19) If yes, name of employer who controlled this workplace 19) Is this the worker s usual workplace? Yes (go to 20) If no, address of worker s usual workplace 20) Business activity of workplace where worker was injured 21) State whether this workplace is a temporary or permanent worksite 22) Do you believe the worker s injury/condition was caused/ contributed by a third party such as a manufacturer/supplier? (eg faulty design of machinery, insufficient labelling of hazardous substances, negligent driving by third party) (go to 23) Yes If yes, give details 23) Do you believe the injury arose as a result of the worker s: violation of any statutory or other regulation? misconduct or breach of safety/work standards? If yes, claim number or date of injury

5 any other circumstances of which WorkCover should be aware? If no to all of the above, go to 24 If yes to any of the above, give details 36) Have you offered the worker a suitable job taking into account his/her injury/condition? Yes If yes, describe the job If no, give reasons why not PRE-INJURY AVERAGE WEEKLY EARNINGS DETAILS 24) Worker s total number of average ordinary hours worked per week prior to injury/condition (excluding overtime) 25) Worker s hourly rate (excluding overtime and allowances) 26) Pre-injury average weekly earnings at time of injury (excluding overtime and allowances) 27) Does the worker work Overtime? Shiftwork? 28) Weekly overtime Weekly shift allowance amount If applicable, please attach a detailed schedule of overtime and/or shift allowance worked over the prior 12 month period, or if the worker has worked for you less than 12 months, the period under your employ. 29) Gross weekly wage over the 3 years prior to injury including overtime and allowances 1 year prior 2 years prior 3 years prior 30) Has the worker returned to work? (go to 35) Yes If yes, date returned to work Time returned to work : am/pm Total number of days lost days 31) Is this a full return to work? (This means a return to full pre-injury duties for full pre-injury hours) Yes (go to 37) If no, give reasons 32) Total hours worker is working per week 33) Worker s hourly rate 34) Worker s gross weekly wage excluding overtime and allowances Weekly overtime Weekly shift allowance 35) If the worker has not returned to work, have you contacted the worker? the worker s treating doctor? (You must offer suitable employment within 12 months of injury as soon as the worker is able to return to work. Penalty for failing to do so is up to 25,000.) 37) Name of occupational rehabilitation provider (if involved) 38) Person to contact at your workplace regarding this claim 39) Position of contact person 40) Contact person telephone Contact person fax 41) address 42) Have you taken up the Buy-out option? 43) Have you completed an Incident tification Form? (please attach a copy) 44) Worker s Claim Form received by you 45) WorkCover Certificate of Capacity received by you 46) If there are any reasons why you believe you are not required to pay compensation as claimed by the worker, please give details EMPLOYER DECLARATION I declare that all of the information provided on this form is, to the best of my knowledge, true and correct. I am aware that to provide any false or misleading information in connection with this claim may be punishable by law. Signature of employer Signature of witness (witness may be any person 18 years or over who is not a relative) Under the authority signed by the claimant, medical information may only be obtained by a person responsible for administering or conciliating the claim. This information may only be used in respect of a matter or for a purpose arising under the Accident Compensation Act 1985 or the Accident Compensation (WorkCover Insurance) Act Unauthorised use of this information can result in a fine of up to 10,000. FOR589/04/07.05

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