Australian Government Claim For Workers' Compensation (Page 2 of 8) in pdf

What you need to do

Step 1—Fill in this form

Please use a black or blue pen to answer the questions in this form.

Answer all questions. Where you are required to make a choice, please tick the appropriate box.

If your answers do not fit in the space provided, please attach additional pages with the details.

When you have answered all the relevant questions, please read and sign the Authorisation, declaration and

acknowledgement on page 5.

Please note: It is an offence to provide false or misleading information in relation to a claim for compensation under the

Seafarers Act.

If this form is not completed in full and if all relevant medical certificates are not attached it may delay a determination of your

claim.

Step 2—Collect the documents you need to provide to the employer

You will need to provide an original medical certificate(s) from a legally qualified medical practitioner (for example a general

practitioner or medical specialist) to prove you have a work-related injury or illness. The certificate must show:

•

a precise medical diagnosis of your condition

•

the relationship between the injury or illness and your employment

•

the certified period of incapacity for work, and

•

any restriction or limitations required for your condition and likely duration of these restrictions (that is, alternative duties

you are able to perform).

Use the checklist on page 6 of this form to make sure you have provided all the required information so your employer can

assess your claim promptly.

Step 3—Lodge this form

When you have completed and signed this form and collected all the documents you need to support the claim, please

make copies of all attachments for your records, including this form.

Provide the claim form and any attachments to the Master of the ship, the Master’s representative, or the employer against

whom you are making the compensation claim. The employer will forward a copy of the claim form and relevant attachments

to the Seacare Authority.

If the employer has gone out of business or no longer operates, you should lodge the original copy of the form and the

attachments with the Seafarers Safety Net Fund, keeping a copy for yourself. The Fund representative is the Seacare

Authority, GPO Box 9905, Canberra ACT 2601.

If you are no longer employed, you must provide this form to the employer you worked for when you were injured or

contracted the illness.

Help—Do you need help with this form?

If you need assistance to complete this form, your supervisor onboard may be able to help you. Otherwise contact your

employer, or your employer’s representative in your home port or your union delegate.

SEA01.1 May 2012

Australian Government Claim For Workers' Compensation Page 2