Queensland Workers' Compensation Claim Form Page 2
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2Employers only: can you confirm that the event occurred at work
Important information—read before agreement
20
(or on the worker’s way to work) and that the worker suffered a work
This section needs agreement by the person completing the form. If
related injury as a result of that event?
the worker and employer are completing the form together, please
yes
complete both sections.
no,
provide relevant information to help us determine the claim
Section F: Privacy notice and statements
Privacy
21
Has a medical certificate been attached to this form?
yes, go to question 22
WorkCover Queensland (WorkCover) is collecting your personal
information in accordance with the Workers’ Compensation and
no, fill in the details below
Rehabilitation Act 2003 in order to assess your entitlement to
Date the doctor signed or issued the certificate?
/
/
compensation and manage your rehabilitation and return to work.
Some of this information may be given to your employer, the Workers’
Diagnosis
Compensation Regulator and service providers for the purpose of
payments, treatment, rehabilitation and return to work.
Doctor’s name
Your information will not be given to any other person unless you have
Practice/hospital name
given your consent, or we are authorised or required by law. For more
information on privacy, visit our website at
Date first seen
/
/
or call us on 1300 362 128.
Worker’s capacity for work
Workers statement
fit to return to normal duties from
Date
/
/
I acknowledge that it is an offence against the Workers’ Compensation
and Rehabilitation Act 2003 to make a statement that is false or
fit for suitable duties (restricted hours) from
misleading. The information I have provided is true and not
Date
/
/
to
/
/
misleading.
I agree to advise WorkCover Queensland if my circumstances change
Restriction/s
or if I become aware of any matter that would make the above
not able to work at all from
information false or misleading. I will advise WorkCover Queensland if
I undertake any employment (paid or unpaid), including self-
Date
/
/
to
/
/
employment, during my claim.
Treatment
I authorise any doctor, health authority, allied health provider,
no further treatment required
rehabilitation provider, or other insurer to disclose to WorkCover
Queensland and its agents any information about my medical history
will require treatment from
relevant to this claim.
Date
/
/
to
/
/
I consent to WorkCover Queensland communicating with all parties,
including injured workers, employers, and medical and allied health
Treatment required
providers by email.
Section E: Wages information
I have read and understand the privacy notice.
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Worker’s wages/salary
Full name
How many hours per week
hrs
/
/
I agree
Date
Gross weekly rate of salary/wages (under award) $
Employer’s statement
Gross normal weekly earnings $
I have read the information provided with this form. I acknowledge that
The normal weekly earnings calculator is available on our website at
it is an offence against the Workers’ Compensation and Rehabilitation
.
Act 2003 to make a statement that is false or misleading. The
23
Worker’s hours of work each day of the week
information that I have provided is true and not misleading.
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
I consent to WorkCover Queensland communicating with all parties,
including injured workers, employers, and medical and allied health
providers by email.
24
Has the employer excess been paid to the worker?
I have read and understand the privacy notice.
no
Full name
yes, gross amount paid $
/
/
I agree
Date
Has the employer continued to pay the worker’s salary or wages
25
during the period of incapacity (in addition to the excess)?
no
What’s next
yes,
provide employer’s bank details for payments to be reimbursed by EFT
We will SMS the injured worker their claim number when we receive
Bank name
the claim (if a mobile number is provided).
After you lodge your claim, we have 20 business days to make a
BSB number
-
Account number
decision on the claim, but we decide most claims within five days.
Account name
If the claim is accepted, it may be managed by one of our customer
26
If the employer is not entitled to claim back all of the GST, what
service centres to assist with return to work. If the claim is for time off
percentage can be claimed?
%
work, the injured worker will be required to complete a Tax file number
declaration and send it to us.
27
eference code or payroll number for the worker
R
If you have any questions about your claim or workers’ compensation
in Queensland, call us on 1300 362 128 or visit our website at
.
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