Workers Compensation Claim Form - Government Of South Australia

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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.
OR
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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