Queensland Workers' Compensation Claim Form
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1
2Claim form
Workers’ Compensation and Rehabilitation Act 2003
Before making a claim, workers need to:
•
notify employers about injuries
•
see a doctor and get a workers’ compensation medical certificate.
Make a claim as soon as possible. We will then decide the claim based on workers’ compensation legislation and advise you of the outcome.
Make a claim
Section C: Employment details
Employer’s full company name and business address
11
Online at
Name
By phone on 1300 362 128
Employer or RRTWC contact
By fax to 1300 651 387
By post to GPO Box 2459, Brisbane Qld 4001.
Number and street
Through a doctor
Suburb/town
Postcode
Telephone
Fax
Section A: Tell us who you are
Email
an injured worker
WorkCover policy number or ABN
an employer
WorkCover Industry Classification (only if >1)
an injured worker and employer filling the form in together
Worker’s occupation
12
Section B: Worker’s details
Surname or family name
1
Was the worker any of the following at the time of the injury?
13
a community service worker
a director of a corporation
2
Given names
Title
a jockey
a member of a
partnership
Title
a student
a trustee
Previous name/s (if applicable)
3
a contractor
self-employed
a worker for another employer
a volunteer
4
Date of birth
/
/
5
Section D: Injury details
Gender
male
female
6
Current residential address
When did the injury happen?
14
Number and street
Date
/
/
Time
:
am
pm
Suburb/town
Postcode
15
What is the nature of the injury and part of the body that is injured?
Postal address
e.g. cut right index finger, fractured leg, lower back strain
7
If this is the same as the residential address please write ‘as above’
Number and street
16
How did the injury happen?
e.g. lifting steel rods from the floor to a bench
Suburb/town
Postcode
8
details
Contact
Where did the injury happen?
17
e.g. workshop floor
Home telephone
Work telephone
Place
Mobile number
Number and street
Email address
Suburb/town
Postcode
What is the claim for?
9
18
Did the injury happen:
time off work (other than the day of the injury)
If your claim is accepted, you will need to complete a Tax file number
working at the normal workplace
declaration
in a road traffic accident while working
medical expenses
at work on a break
10
Worker’s bank details
on a journey to or from work
We pay claim and medical reimbursement payments by electronic funds transfer
away from work during a recess period
Name of bank
working away from the normal workplace
BSB number
-
Account number
When was the employer advised about the injury?
19
Account name
Date
/
/
Who was the injury reported to?
Name
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