Australian Government Claim For Workers' Compensation Page 4
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8About the journey
14 Name of the ship you were employed on when the
injury or illness happened
17 Where were you travelling?
From
Claim details
To
15 For what are you claiming (tick all that apply)
Note: This question does not limit your entitlement to
Via
make further claims in relation to the injury or illness.
18 Did you travel a route other than the direct route?
You do not need to complete another claim form if
you wish to make a claim for the below benefits in the
No
Yes
Please attach a map of the
future.
route taken
Lost wages resulting from an incapacity for work
19 Was the journey interrupted
Medical and related expenses
No
Yes
Please attach a separate sheet
Travel expenses attending medical examination/
stating the reason for, and the
rehabilitation (only round trips of 50 km or more
duration of, the interruptions
are reimbursable)
20 Did the police attend?
Alterations, aids or appliances
Household and attendant care services
No
Yes
Please attach a copy of the Police
Statement or provide the Police
Compensation for property loss and/or damage
Event number or Police reference
Duty status
number
16 What was your duty status when the injury or
illness happened? (Tick applicable box)
Injury or illness details
go to question 21
(a) On duty
21 When were you injured or when did you first notice
on the ship
you were ill? Give approximate time if exact time is
not known.
on the ship and on an authorised break
/
/
away from the ship
Date
away from the ship and on an authorised
am/pm
Time
break
22 Did you report the injury or illness to your
(b) Off duty
go to question 21
employer?
on the ship
No
Yes
When did you report it?
away from the ship (during periods of ordinary
/
/
recess)
Date
(c) While travelling to or from
go to question 17
am/pm
Time
a ship
a training facility
Who did you report it to?
(d)
While attending an approved course of
Name
study
go to question 21
Position
(e)
Other—please specify
go to question 21
2
SEA01.1 May 2012
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