Australian Government Claim For Workers' Compensation (Page 6 of 8) in pdf

Australian Government Claim For Workers' Compensation Page 6

Past injuries or illnesses details

Loss of, damage to, property details

32 Have you ever suffered a similar injury or illness to

38 Are you claiming for the loss of, or damage to any

the one you are claiming for?

property? Property is defined as ‘property used by an

employee restricted to an artificial limb or other artificial

Yes

Go to question 38

substitute, surgical or similar aid or an appliance, for

example glasses, false teeth’.

33 When did that injury happen or when did you

notice you were ill? Give approximate date if exact

Go to the ‘Authorisation, declaration

date is not known.

and acknowledgement’ on the next

page

Yes

Please attach receipts or evidence of

34 Please describe, in your own words, that injury

purchase or replacement of repaired

property

39 Provide details of the property that was lost or

damaged

35 Name of your employer at that time

40 Please describe the events that led to the loss of,

or damage to, the property

36 Did you claim compensation?

Yes

Were you paid compensation?

Yes

37 Name of the doctor, medical specialist and/or

hospital that treated you for the previous injury or

illness

SEA01.1 May 2012

Australian Government Claim For Workers' Compensation Page 6