Workers Compensation Claim Form - Government Of South Australia printable pdf download

Workers compensation

claim form

South Australians with a work-related injury can lodge a claim

Important information for workers

for workers compensation and may be entitled to income

Report any work-related injury to your employer as

maintenance payments and/or reimbursement of medical

soon as possible and talk to them about a plan to stay

expenses paid.

at or return to work.

Talk to your doctor about work tasks you can still do and

Before making a claim, workers need to:

obtain a WorkCover Medical Certificate.

Be actively involved in your treatment, rehabilitation and

notify their employer about the injury

return to work, or stay at work plans.

see a doctor and get a WorkCover Medical Certificate.

Important information for employers

How to make a claim for compensation:

This form must be submitted to your claims agent within

five business days of you receiving it.

Complete this form

Step 1

There are financial incentives for employers who forward

Wherever possible, the worker and the

the workers compensation claim form together with the

WorkCover Medical Certificate (if you have been given one)

employer should complete this form together.

within five calendar days of receiving the form from the

A representative, such as a treating doctor, a

worker. For more information on financial incentives visit

worker’s friend or a rehabilitaton and return to work

coordinator can assist the worker by completing

Immediately notifiable incidents

It is a legal requirement under the Work Health and Safety

information in the form with the worker’s consent.

Act 2012 for a person who conducts a business

Sign the Medical Authority and

or undertaking to notify Safework SA of:

Step 2

• the death of a person

declarations (page 4)

• a serious injury or illness of a person including immediate

Lodge this form

treatment for amputation, serious head, eye, burn and

Step 3

laceration injuries, separation of skin from underlying

South Australian businesses registered under the

tissue, spinal injury or loss of body function; medical

WorkCover Scheme and their worker must ensure

treatment within 48 hours of exposure to substance;

this completed and signed form and WorkCover

• a dangerous incident that exposes a worker or any other

Medical Certificate are sent to the employer’s

person to a serious risk to a person’s health or safety

emanating from an immediate or imminent exposure,

claims agent, either:

whether or not an injury has actually occurred and

however minor.

Employers Mutual SA

Notify SafeWork SA by calling 1800 777 209 or emailing

GPO Box 2575, Adelaide SA 5001

help@safework.sa.gov.au

.au

Copy of the WHS Act available from

Fax (08) 8127 1200

Serious penalties arise from failure to notify SafeWork SA

of notifiable incidents. SafeWork SA receives WorkCover SA

Phone (08) 8127 1100 or 1300 365 105

claims data.

Gallagher Bassett Services Pty Ltd

Need help?

GPO Box 1772, Adelaide SA 5001

.au

If you have any questions about this form

Scan with

Fax (08) 8177 8451

a QR

or claiming workers compensation,

reader to

contact WorkCover Assist on 13 18 55 or

visit our

Phone (08) 8177 8450 or free call 1800 664 079

website

visit

To find which is the employer’s claims agent, use

Visit

for information on rights

WorkCoverSA’s Claims Agent Lookup Service at

and responsibilites for both workers and employers.

To contact WorkCoverSA in a language other than English call the

Self Insured / Crown Employers

Interpreting and Translating Centre (ITC) on 1800 280 203 and ask

Most of South Australia’s largest private and public sector

the consultant to organise a telephone interpreter in your language

organisations are self-insured, managing their own workers

and to then be connected to WorkCoverSA on 13 18 55.

compensation claims. Workers of self-insured businesses

People with hearing / speech impairments can contact WorkCover

with a work-related injury should speak to their employer

Assist using the National Relay Service.

about lodging a claim.

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Workers Compensation Claim Form - Government Of South Australia

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