Claim Form - Return To Work - Government Of South Australia
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The Return to Work scheme provides timely, personalised support and
Important information for workers
services to workers and their employers following a work injury.
>
Report a work injury to your employer as soon as possible and
South Australians who have been injured at work may be eligible for
talk to them about a plan to stay at or return to work.
income support and/or the reimbursement of medical expenses and
>
Talk to your doctor about work tasks you can still do and obtain a
other return to work services.
Work Capacity Certificate.
Before making a claim workers need to
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Be actively involved in your treatment, recovery and return to
work, or stay at work plans.
>
notify their employer about the injury
Important information for employers
>
see a doctor to get a Work Capacity Certificate.
>
This form must be submitted to your claims agent within five
How to make a claim
business days of you receiving it.
Step 1
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There are financial incentives for employers who forward the
Complete this form
claim form together with the Work Capacity Certificate (if you
Wherever possible, the worker and the employer should
have been given one) within five calendar days of receiving
complete this form together. A representative, such
the form from the worker. For more information on financial
as a treating doctor, a worker’s friend or a Return to
incentives visit
Work Coordinator can assist the worker by completing
>
Notifiable incidents
information in the form with the worker’s consent.
It is a legal requirement under the Work Health and Safety Act
2012 for a person who conducts a business or undertaking to
Step 2
Sign the Medical Authority and declarations (page 4)
notify SafeWork SA of:
• the death of a person
Step 3
Lodge this form
• a serious injury or illness of a person including immediate
South Australian businesses registered under the Return
treatment for amputation, serious head, eye, burn and
laceration injuries, separation of skin from underlying tissue,
to Work scheme and their workers must ensure this
spinal injury or loss of body function; medical treatment within
completed and signed form and Work Capacity Certificate
48 hours of exposure to substance
are sent to the employer’s claims agent, either:
• a dangerous incident that exposes a worker or any other
person to a serious risk to a person’s health or safety
Employers Mutual SA
emanating from an immediate or imminent exposure, whether
GPO Box 2575, Adelaide SA 5001
or not an injury has actually occurred.
.au
Please notify SafeWork SA by calling 1800 777
209.
Fax (08) 8127 1200
For more information about SafeWork SA please visit
Phone (08) 8127 1100 or 1300 365 105
OR
Serious penalties could arise from failure to notify SafeWork SA of
notifiable incidents. SafeWork SA receives ReturnToWorkSA claims data.
Gallagher Bassett Services Pty Ltd
GPO Box 1772, Adelaide SA 5001
To contact ReturnToWorkSA in a language other than English call the
Fax (08) 8177 8451
Interpreting and Translating Centre (ITC) on 1800 280 203 and ask the
consultant to organise a telephone interpreter in your language and to
Phone (08) 8177 8450 or free call 1800 664 079
then be connected to ReturnToWorkSA on 13 18 55.
To find which is the employer’s claims agent, use the Claims Agent
People with hearing / speech impairments can contact
13 18
55.
Lookup at
or call
ReturnToWorkSA using the National Relay Service.
Need help?
Self-Insured / Crown employers
Most of South Australia’s largest private and public sector organisations
If you have any questions about this form contact
are self-insured, managing their own workers compensation claims.
ReturnToWorkSA on
Workers of self-insured businesses with a work injury should speak to
13 18 55 or
their employer about making a claim.
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