Application for Compensation This Application for Compensation form for injured workers is an approved form under the Workers Compensation and Rehabilitation Act 2003 (the Act). The general information contained on this and the following page is not part of the approved form. The information will help you to understand your obligations and WorkCover s claims process. 1 2 3 4 5 6 7 General information What to do when you are injured at work the claims process See your doctor as soon as possible and get a Workers Compensation Medical Certificate. Tell someone at work about your injury (e.g. your supervisor) even if it is minor. Your employer needs to know about your injury so they can send WorkCover an Employer s Report. Apply for compensation by phoning 1300 362 128 or sending WorkCover: this form a Workers Compensation Medical Certificate a Tax File Number Declaration form (a Tax File Number Declaration is only needed if you have time off work). Send your documents directly to WorkCover or give them to your employer to send. You can find our postal addresses on this form. You should lodge your application as soon as possible preferably within 28 days of first seeing a doctor about your injury. WorkCover receives your application documents and your employer s Employer s Report form. WorkCover assesses your application according to workers compensation legislation, determining whether: you are a worker 1 you have suffered an injury 1 your employment was a significant contributing factor to your injury. To assess your application we may: talk to you, your employer or your doctor talk to any witnesses ask you to visit an independent medical practitioner ask you for further information. Application accepted. You will receive compensation benefits. WorkCover will manage your claim including any further rehabilitation if needed. Application not accepted. You can request a review through Q-COMP if you are unhappy with WorkCover s decision. 1. The Act defines who is a worker and what is an injury for the purpose of workers compensation. Making an application for compensation important information for workers Can I apply for workers compensation? Anyone defined as a worker under the Workers Compensation and Rehabilitation Act 2003 (the Act) can apply for workers compensation. If you are unsure whether or not you are a worker you can still make an application and WorkCover will assess this once your application is lodged. You can apply for compensation regardless of who or what caused your work-related injury. Once you have lodged your application, WorkCover must assess it in accordance with the Act. How long will the assessing process take? WorkCover must make a decision within three months of receiving your application. If we do not make a decision within that time you have the right of review. You can contact Q-COMP, the Workers Compensation Regulatory Authority, on 1300 361 235 for further information. You can help minimise delays by: letting your employer know about your injury as soon as possible (you may want to give them a copy of this form) answering every question on this form making sure you have signed this form making sure you provide accurate information (e.g. an incorrect date of injury will cause delays in processing your claim) sending all the documents needed including: - a Workers Compensation Medical Certificate covering you for the correct dates - any relevant medical accounts - if needed, a Tax File Number Declaration available from any Australian Taxation Office. Telephone lodgments You can call 1300 362 128 and apply for compensation over the phone. WorkCover will fill out the application form for you and will mail it to you to check, sign and return to WorkCover with your Workers Compensation Medical Certificate and other relevant documents. It may help to make notes about your injury and how it happened before you phone WorkCover. If you are making a claim for a psychological/psychiatric injury, you will need to apply for compensation by mail or in person. However, you can call 1300 362 128 if you would like to check that you have provided the information needed.
Important information for injured workers Lodging by mail or in person If you need help filling out your application please call WorkCover on 1300 362 128. Our Customer Service Officers will put you through to someone who can help. You can also talk to your employer or union. You will need to send your application documents to your nearest WorkCover office: Brisbane GPO Box 2459, Brisbane Qld 4001 Cairns PO Box 851, Cairns Qld 4870 Ipswich PO Box 575, Ipswich Qld 4305 Logan PO Box 4247, Loganholme Qld 4129 Mackay PO Box 486, Mackay Qld 4740 Maryborough PO Box 137, Maryborough Qld 4650 Rockhampton PO Box 1408, Rockhampton Qld 4700 Southport PO Box 419, Southport Qld 4215 Strathpine PO Box 5399, Brendale Qld 4500 Sunshine Coast PO Box 5802, Maroochydore Business Centre Qld 4558 Toowoomba PO Box 32, Toowoomba Qld 4350 Townsville PO Box 1312, Townsville Qld 4810 You can also deliver your application in person. Please call 1300 362 128 for the address of your nearest WorkCover office. Contacting WorkCover WorkCover will let you know as soon as a decision has been made on your application. To check the progress of your application, please phone 1300 362 128 and ask to speak with a Claims Assessor. Your responsibilities If your application for compensation is accepted you will receive compensation benefits. For example WorkCover may reimburse necessary and reasonable medical expenses you have paid or pay you weekly compensation if you need time off work. To receive compensation benefits you have certain responsibilities that are outlined in workers compensation legislation. These include: completing and signing all necessary forms making sure all information is true and not misleading participating in rehabilitation (including planning your rehabilitation and participating in set programs) letting us know when your condition or treatment changes or if you return to any kind of work. There are penalties if you do not fulfil any of these responsibilities for example WorkCover may have to suspend your compensation benefits or prosecute you for an offence under the Act. It is important to understand that your doctor needs to get prior approval from WorkCover for any private hospitalisation costs otherwise the cost may not be covered even if your application is accepted. You or your doctor can call WorkCover for further details. Release of information WorkCover Queensland collects information on this form to assess your claim for workers' compensation and to assist in managing your injury if your claim is accepted. Please ensure the information you provide on this form is complete and accurate, otherwise we may not be able to fully provide you with our services. Please let us know if your details change, or if you believe the personal information we hold about you is inaccurate. We will then take reasonable steps to update and/or correct your personal information. Please note that if you have not reported your injury to your employer, we may disclose the information you provide on this form to your employer for verification of information relevant to your claim. Also, we may be required or authorised by law to give information about your claim to another person (eg. Courts, Australian Taxation Office, other insurers etc). WorkCover undertakes all reasonable measures to protect your privacy by collecting, using, storing and disclosing the personal information we hold about you in accordance with Queensland Government privacy requirements. For further information on privacy, visit our web site at www.workcoverqld.com.au or call 1300 362 128 and ask to speak with our Privacy Officer. Payment information If WorkCover accepts your application you may be entitled to receive compensation benefits. To receive any benefits via Electronic Funds Transfer (EFT), simply complete the Payment details section on this form. EFT is a fast, reliable and convenient way to receive compensation. By choosing EFT you can avoid delays in waiting for the mail, depositing your cheque and waiting for it to clear. When completing the Payment details section please make sure you provide: the BSB number for the branch where your account was opened (you can find this on your account statements, deposit book/cheque book) provide all six digits of your BSB number. WorkCover will send you a letter confirming your banking details before any payment is made. Your banking details remain confidential. They are only used for the duration of your claim and will not be released. WorkCover Queensland cannot withdraw money from your account. Hint: You can remove this information page and keep it for your records.
Application for Compensation form pursuant to section 132 of the. Please complete this form using blue or black pen. Worker s details 1 2 Surname or family name Given names 15 16 Employer s trading name (if applicable) Employer s telephone and fax number (telephone) (fax) 3 4 5 6 7 8 9 10 11 12 13 Preferred title o Mr o Mrs o Ms o Miss o Dr o Other Previous or other names (if applicable) Gender o Male o Female Date of birth / / Present residential address Postal address (if this is the same as your residential address please write as above ) Telephone no. (home) (fax) Email address Do you require an interpreter? If yes, what language do you speak? (work) (mob.) Have you ever claimed workers compensation before in your current name or any other name? If yes, please provide details (e.g. in what name, in which State, nature of injury, etc) Do you receive or intend to claim benefits from Centrelink or from any other source (e.g. superannuation company or income protection insurer)? If yes, what type? Employment details 14 Employer s full name and business address Full name 17 18 19 20 21 22 23 24 What is your occupation? (Please be specific e.g. farmhand, labourer) When did you commence employment with your current employer? Date / / Please indicate if you were employed as one or more of the following at the time of your injury and state the name of the organisation/employer o a worker o a community service worker o a jockey o a self-employed individual o a student o a volunteer o a director of a corporation o a member of a partnership o a trustee o a contractor Name of organisation/employer Are you employed or self-employed in any job other than the one in which you were injured? If yes, provide details of the employer Name At the time of your injury were you either: a) working temporarily in Queensland? b) working outside of Queensland but in Australia? c) working overseas? Please indicate your employment type at the time of injury o part time o full time Please indicate if you were permanent or casual at the time of injury o permanent o casual Did the injury occur during your current employment? If no, who was your employer at the time? Injury details 25 When did the injury happen? (If your injury happened over time please go to question 26). Date / / Time am/pm
26 27 28 Did your injury happen over a period of time? If yes: a) When did you first experience symptoms? / / b) When did you first see a doctor? / / Did the injury happen: o working at your normal workplace? o road traffic accident while you were working? o at work on a break? o journey to or from work? o away from work during a recess period? o working away from your normal workplace? How did the injury happen? Please explain what you were doing at the time of your injury and how your injury happened (e.g. lifting steel rods from the floor to a bench). If you need more space, please use the back page of this form. 32 33 34 35 If yes, please provide details Did you stop work because of the injury? If yes, please provide: Date / / Time am/pm Have you returned to work? If yes, please provide: date / / In what capacity? (e.g. normal or light duties). Did you advise your employer about your injury? (e.g. verbally or by written report) If yes: a) when did you advise your employer? Date / / b) who did you report the injury to? 29 Where did the injury happen? (e.g. workshop Smith St, Smithtown) 36 37 If the injury occurred on your way to or from work, please state your starting time (if on your way to work) or finishing time (if on your way home from work) for that day Time am/pm Was a motor vehicle(s) involved? If yes, please provide details of registration number(s) and owner(s) of the vehicle(s) 30 What is the nature of your injury and what part of your body is injured? (Please list all specific injuries e.g. cut right index finger, sprained left ankle, lower back injury.) 38 Did police attend the accident? If yes, officer s name 31 Was there any object or any other person involved in the event that caused your injury? (e.g. machinery, a contractor) Branch 39 Did an ambulance attend the accident? Please continue to answer questions 40-43 on the following page. IMPORTANT: You must sign this form before you send it to WorkCover.
40 41 Please provide the name, address and telephone number of any witnesses to the incident. (If you need more space please use the back of this form). Name Address Telephone no. Did you receive medical treatment following your injury? If yes, please provide: Doctor/hospital: Name Surgery Hospital: o public o private o in-patient o out-patient Claimant s statement In completing this Application for Compensation form, I acknowledge that I have read the information provided on the front page. I acknowledge that it is an offence against the Workers Compensation and Rehabilitation Act 2003 to make a statement that is false or misleading. I hereby authorise any doctor, health authority, allied health provider, rehabilitation provider or other insurer to disclose to WorkCover Queensland and its agents any information regarding my medical history relevant to this claim. I agree to advise WorkCover if there is any change in my circumstances or if I become aware of any matter that would make the above information false or misleading. In particular, I will advise WorkCover upon the occurrence of any change in my employment status during the currency of my claim. I understand WorkCover may be required or authorised by law to release information or documents to other parties. Title Payment details Given name/s Have you previously suffered any similar injury or condition? o yes, please provide details. o no Will you be providing your employer with a copy of your completed Application for Compensation form? There is more space provided over the page if you need to provide more information or did not have room to answer any of the questions on this form. This form must be signed by the injured worker unless they are unable to complete it. In these cases, it must be completed and signed by an agent of the injured worker. The information I have provided is true and not misleading. This payment section is not part of the approved form and will be used to process compensation payments once an application is accepted. By choosing EFT you can avoid delays in waiting for the mail, depositing your cheque and waiting for it to clear. 42 43 Full name Claimant s signature Complete this section if this form was completed and signed by an agent on behalf of the injured worker. Agent s given name Agent s surname/family name Agent s address Reason claimant unable to sign Bank details Name of Bank, Building Society or Credit Union Date / / Agent s signature (if claimant unable to sign) Date / / Surname or family name Address Branch where your account was opened Type of account (e.g. cheque or savings) The information you provide in this section is confidential. Your banking details will only be used for the duration of your claim. BSB number (please see the information pages for assistance if needed) Account number Signature Date / / Account held in the name/s of Special note: If you are providing a photocopy of this completed form to your employer, you may want to cover your banking details before you photocopy it so that this information remains confidential.
Important Before you send this form to WorkCover make sure you have: o answered all of the questions o read the claimant s statement and signed the form o attached a Workers Compensation Medical Certificate to this form. Supplementary details Use this space if you did not have room to answer any of the questions on this form.