EQUILAW Solicitors Ph: 02 6542 5566 Market House 4 Market Street Muswellbrook NSW 2333 Fax: 02 6543 4397 info@equilaw.com.au equilaw.com.au WORKERS COMPENSATION QUESTIONNAIRE & CHECKLIST (Attach the Workers Compensation Journey Claim Supplementary Questionnaire if required) Bring this completed questionnaire with you when you attend your first appointment. 1. Personal Details Title: Surname: Given Names: Have you ever been known by another name?: Yes No If yes, provide details: Residential address: Postal address: (if differs) Medicare No. Birth date: Age: Country of birth: Home Ph: Mobile no.: Work Ph: Fascimile E-mail: 2. Interpreter If country of birth When did you arrive in Australia (if born overseas)? Language spoken at home. Do you need an interpreter to help you with your claim? language? Yes No If Yes, what language page 1 of 23
3. Previous advice in relation to incident Have your previously seen a solicitor in respect to this incident? Yes No If Yes, provide details Solicitor Firm Name & Address Phone Appt. Date 4. Driver s Licence Have you ever held a Driver s Licence? Yes No Year first licenced: Driver s Licence No. Please provide a copy of your Driver s License Driver s Licence Number Yes No If Yes, reason for cancellation or suspension 5. Employment What was your employment situation before the incident? Self employed Full Time Part Time Retired Casual Student/child Home Duties Not Working Other (provide details) Pensioner (provide details) Details: Have you lost income because of the incident? Yes No Are you still losing income? Yes No page 2 of 23
5. Employment continued Is the work you do, or are your weekly earnings different, because of the incident? Yes No If Yes, Please provide details below: How many separate periods of time have you been away from work because of the incident? (include short periods when you went for treatment or rehabilitation) Work time lost (weeks/days/hours) Date from Date to Have you returned to work? Yes No If No, when do you expect to return to work? Don t know Employment details Name of Employer Contact person s name Contact Ph Workplace address: Usual weekly working hours: per day: per week: Usual weekly earnings (including overtime, regular bonuses & commission): Description of duties: Do you have a contract of employment? Yes No - If Yes, please provide a copy. page 3 of 23
5. Employment continued Were there any periods in which you were acting in a higher position? Yes No - If Yes, please provide details: Are you covered by an Award? Yes No - If so, please provide a copy. Were there any changes to the Award during the period claimed? Yes No - If yes, please provide copies of any previous Awards. Do you have a copy of your last payslip prior to the incident? Yes No - If yes, please provide a copy. Did you change jobs during the period claimed? Yes No - If yes, please provide details: Second job Did you have a second job before the incident? Yes No Name of Employer Contact person s name Contact Ph Workplace address: Usual weekly working hours: per day: per week: Usual weekly earnings (including overtime, regular bonuses & commission): Description of duties: Do you have a contract of employment? Yes No - If Yes, please provide a copy. Were there any periods in which you were acting in a higher position? Yes No - If Yes, please provide details: Are you covered by an Award? Yes No - If so, please provide a copy. Were there any changes to the Award during the period claimed? Yes No - If yes, please provide copies of any previous Awards. page 4 of 23
5. Employment continued Do you have a copy of your last payslip prior to the incident? Yes No - If yes, please provide a copy. Did you change jobs during the period claimed? Yes No - If yes, please provide details: Self Employment Have you lost income from self-employment in your business because of the incident? Yes No Not applicable Name of business Nature of business Workplace address Phone Estimated earnings loss (Give details of how much you believe you have lost and how you calculated the amount. You will be asked to give CTP insurers copies of your taxation returns, group certificates and assessment notices where available.) If you are self employed have you hired anyone to replace you? Yes No If yes, give details of replacement including name, address, duties perfomed and cost. If no, explain why not. If you were self employed, did you have a second job before the incident? Yes No Have you received or will you receive any money for being unable to work because of your injuries? (e.g. sick leave or holiday pay, social security benefits, workers compensation or insurance payment.) Yes No If yes, please provide details: Before the incident, had you made any firm arrangements to start a new job, stop work, change your duties, working hours or earnings? Yes No If yes, please provide details: page 5 of 23
6. Your Employment History Please provide details of all of your employers since leaving school to date. Employer name and address Description of duties Period of time employed page 6 of 23
7. Comparable Earnings - Please provide copies of proof of earnings of 2 people in comparable positions to yours. 8. Financial Details Accountant Accountant s Name Phone Address Tax Returns Do you have completed tax returns for the period 5 years to date? Yes No - If Yes, please provide a copy. Financial Advisor Do you have a Financial Advisor? Yes No If Yes, please provide the following details. Financial Advisor s Name Phone Address Super Fund Are you in a Super Fund? Yes No If Yes, please provide the following details. Name of Super Fund Phone Address Bank Details Bank Name Account Name BSB No Account No. page 7 of 23
9. Marital Status Married (legal or defacto) Single Separated Divorced Widowed If you are married, do you have a copy of your Marriage Certificate? Yes No - If Yes, please provide a Certified Copy of your Marriage Certificate to this firm. Spouse s Name Spouse s Birth Date Spouse Employed? Yes No Name of Spouse s Employment Spouse s Workplace Address Spouse s Gross Weekly Earnings Spouse s Nett Weekly Earnings 10. Children Do you have Dependent Children? Yes No Name Date of Birth 11. Tertiary Education or Qualifications Year left school Do you have a tertiary education? Yes No Institute Year Qualification page 8 of 23
12. Details of Incident Time Date Location Street Name Briefly, describe what happened: What part of your body was injured? What was the nature of the injury? Were you carrying out duties for your employer at the time of the incident? Yes No If so, please provide name and address of employer at the time of the incident (check your Income Tax Group Certificate and provide the name shown on that Certificate. Please provide date of Notice of Injury. To whom did you report the injury? Did you make an entry in the Injury Report Book? Yes No If yes, what date did it get entered? Do you have a copy of the Report of Injury? Yes No - If so, please provide copy of the Report of Injury. When did you stop work? Who did you advise at work that you would have to stop work because of the injury? Are you required to wear prescription glasses while driving/working? Yes No If the answer is Yes to the question above, were you wearing your glasses at the time of the incident? Yes No page 9 of 23
12. Details of Incident continued Do you require a hearing aid? Yes No If the answer is Yes to the question above, were you wearing a Yes No hearing aid at the time of the incident? Were you travelling to or from work when the incident happened? Yes No If yes, did the incident occur on your usual journey to or from work? Yes No If yes, had you changed your usual journey to or from work? Yes No Was the incident your fault? Yes No Did the incident occur as the result of an unsafe system of work designed by your employer? Yes No If so, please give details below Did the incident occur as the result of unsuitable, unsafe or defective plant or equipment? If so, please give details below Yes No Did the incident occur as the result of a situation about which complaints had been made prior to your incident and which complaints had not been attended to prior to your incident? Yes No If so, please give details below Did the incident occur as the result of a casual, careless or negligent act by some other person? If so, please give details below Yes No Did the incident occur as the result of any carelessness or negligence or fault of any other person or organisation? Yes No If so, please give details below page 10 of 23
13. Others Involved and Witnesses to the Incident Others Involved Was anyone else involved in the incident? Yes No Full Name Address Phone (and your relationship to the witness) (home, work, mobile) Witnesses Were there any other person/s who witnessed the incident? Yes No Full Name Address Phone (and your relationship to the witness) (home, work, mobile) page 11 of 23
14. Workers Compensation claim Have you made a claim for Workers Compensation? Yes Date Claimed No If yes, please provide name and address of the Workers Compensation Insurer. Name of Workers Compensation Insurer contact. Have you been given a Claim Number? Yes No If so, please provide the Claim Number Do you have a copy of the Claim Form? Yes No - If so, please provide copy of the Claim Form. Have you received weekly payments of compensation? Yes No If yes, please provide details of your payments below. - Please provide copies of all correspondence and documents received from the Workers Compensation Insurer. 15. Medical Ambulance Did you require an ambulance on the day of the incident? Yes No Do you recall any conversations that you had with the ambulance officers treating you at the scene? If so please outline what those conversations were. Yes No Hospital Did you go to a hospital after the incident? Yes No If so, which hospital? Were you treated at the hospital? Yes No Date treated Were you admitted to the hospital? Yes No Date admitted Have you been discharged from the hospital? Yes No Date discharged page 12 of 23
15. Medical continued Medical Practitioner Did you go to a medical practitioner after the incident? Yes No If so, please provide details of the name and address of the medical practitioner? Did you receive treatment for your injuries? Yes No Date treated Details of Previous Injuries/Medical Problems Please provide details of all previous injuries or medical problems, whether resulting from work accidents, non work accidents or other causes, including motor vehicle accidents. Type of Injury Name & Address of Employer (if a work injury) Period off Work Insurance Company Involved Full recovery made? Yes/No page 13 of 23
15. Medical continued Medical Treatment Before the Incident Name of your normal Medical Practitioner? Please list all Medical Practitioners you have seen in the last 5 years: Name Speciality Name, Address & Phone No. of Surgery Treatment ongoing? (Yes/No) page 14 of 23
15. Medical continued Please list all Medications that you were taking prior to the incident. 1 Name of Medication Dosage 2 3 4 5 6 7 8 9 10 Medical Treatment Since The Incident Please list all medical treatment providers you have seen since the incident, including GP s, specialists, hospitals, physiotherapists, chiropractors and any other treatment providers. Treatment Name Speciality Name, Address & Ph of Surgery ongoing? (Yes/No) page 15 of 23
15. Medical continued Have you had any x-rays, CT scans or investigations undertaken since the incident? Yes No If so, please provide details below. Date Type Where - If so, please provide copies of all reports, documents, x-rays, CT Scans or any other investigations in relation to medical treatment since the incident. Have you received any Medical or Workcover Certificates? Yes No - If so, please provide copies of these Certificates. Have any treatment or rehabilitation plan(s) that has been developed for you? Yes No If so, provide details below. Name Address & Phone number Treatment page 16 of 23
15. Medical continued Please list all Medications that you now need to take since the incident. Name of Medication (since the incident) Dosage 1 2 3 4 5 6 7 8 9 10 16. Out of Pocket Expenses Have you incurred any out of pocket expenses in relation to the incident? (e.g. medical appointments, travel to and from appointments, pharmacy expenses) Yes No - If yes, please provide details below AND provide us with copies of receipts. Date Details of Out of Pocket Expenses Paid or Un (tick) un un un un un un un un un page 17 of 23
16. Out of Pocket Expenses continued un un un un un un un un un un un un un un un un un un un un un un un un un page 18 of 23
17. Injuries Please list your injuries from the incident. (List all injuries and affected areas of the body) How do these injuries affect you now? (The effect of your injuries may change over time) Previous Injuries Have you had any other injuries, disability or illness, before or since the incident to the same part(s) of your body? Yes No If yes, please provide details below Date Injury or Illness Treatment Doctor s Name Address (practice or surgery) Have you ever made a claim for personal injury compensation, workers compensation or other damages? (eg.slip & fall, assault, medical negligence, motor accident) Yes No If yes, please provide details below. Date of Injury Insurance Company Claim or Reference no. Type of Claim page 19 of 23
18. Care Have you required personal assistance or care at home since the incident? Yes No If so, who provided this assistance? Please provide details of the hours that person spent assisting you. Phone Name Address (home, work & mobile) Dates & Hours per day Have you required assistance around the house, including cleaning, gardening, mowing, or any other duties? Yes No If so, who provided this assistance? Please provide details of the hours that person spent assisting you. Name Address Phone (home, work & mobile) Dates & Hours per day Have you required assistance in getting to and from medical appointments? Yes No If so, who provided this assistance? Please provide details of the hours that person spent assisting you. Phone Name Address (home, work & mobile) Dates & Hours per day Have you for any of this assistance? Yes No page 20 of 23
19. Photographs Do you have any photographs of the incident scene? Yes No Do you have any photographs of injuries you received in the incident? Yes No Do you have a recent passport size colour photograph of yourself? Yes No - If the answer in any of the questions above is Yes, please provide copies 20. Birth Certificate Do you have your Birth Certificate? Yes No - If so, please provide a Certified Copy of your Birth Certificate. Do you have your husband/wife/partner s Birth Certificate? Yes No - If so, please provide a Certified Copy of your husband/wife/partner s Birth Certificate. Do you have your children s Birth Certificates? Yes No - If so, please provide Certified Copies of your children s Birth Certificates. 21. Personal Property Was any of your personal property damaged in the incident? Yes No If yes, please provide details below. 22. Additional information Do you wish to add anything further? Yes No If so, please indicate what you wish to add. page 21 of 23
23. Declaration Do you declare the information you have supplied is true and correct to the best of your knowledge and belief? Yes No Signature Witness Dated page 22 of 23
23. Checklist Before attending your initial appointment, please ensure that you have attached copies of the following documents, if you have them. Page 2 Driver s Licence Copy of your current driver s licence. Page 3 & 4 Employment Copy of your Contract of Employment. Copy of your Award. Copy of your Previous Award. Copy of your last payslip prior to the incident. Pages 4 & 5 Second Job Copy of your Contract of Employment. Copy of your Award. Copy of your Previous Award. Copy of your last payslip prior to the incident. Page 7 Comparable Earnings Copies of proof of earnings of 2 people in comparable positions to yours. Page 7 Tax Returns Copies of your Tax Returns for the period 5 years prior to the incident to date. Page 8 Marriage Certificate Certified Copy of your Marriage Certificate. Page 9 Report of Injury Copy of the Report of Injury. Page 12 Claim Form Copy of the Claim Form. Page 12 Workers Compensation Insurer Copies of all correspondence and documents received from the Workers Compensation Insurer. Page 16 Medical Treatment Copies of all reports, documents, x-rays, CT Scans or any other investigations in relation to medical treatment since the accident. Copies of any Medical or WorkCover Certificates. Page 17 Out of Pocket Expenses Copies of any receipts that you may hold. Copies of any receipts that you may hold in relation to payments made by the insurer. Page 21 Photographs Copies of any photographs that you may have of the vehicles at the incident scene or your injuries. A recent passport size colour photograph of yourself. Page 21 Birth Certificates Certified Copy of your Birth Certificate. Certified Copy of your husband/wife/partner s Birth Certificate Certified Copies of your children s Birth Certificates. page 23 of 23