Australian Government Claim For Workers' Compensation (Page 7 of 8) in pdf

Authorisation, declaration and

I acknowledge that:

•

the employer’s workers’ compensation insurer may

acknowledgement

exercise the authorities and rights of my employer

Please read and sign this authorisation, declaration and

in relation to this claim, whether those authorities or

acknowledgement.

rights are conferred on my employer by this claim

form or by the Seafarers Act

Please note that all references to ‘the employer’ mean the

•

it is an offence to provide false information in relation

employer against whom this claim is made.

to a claim for compensation under the Seafarers Act

I authorise and consent to:

•

I must advise my employer if I claim or receive benefits

•

any medical practitioner, hospital, laboratory,

under state workers’ compensation legislation, or

rehabilitation provider, or other health practitioner

benefits from Centrelink, such as Sickness Allowance.

providing details of any consultation, treatment or

report in connection with this injury or illness to the

I understand that the information is required for the

employer or any relevant former employer, upon

purposes of determining and managing my compensation

production of this authority or photocopy thereof

claim and/or assessing my suitability to undertake a

•

provide to the employer details of wages or

rehabilitation program and/or assist Comcare and the

remuneration obtained in any employment while

Seacare Authority in any of their functions under the

receiving compensation benefits in respect to this

Safety Rehabilitation and Compensation Act 1988 and the

claim

Seafarers Act, including research.

•

information being obtained from any relevant authority

to establish my seagoing work history.

Your name

I further authorise and consent to a photocopy of

this Authority and Consent as sufficient evidence of my

authority and consent to discuss or provide the information

Date of birth

requested.

Your signature

I declare that:

•

I elect to claim benefits under the Seafarers Act and

not under an industrial award or agreement

•

I will advise my employer of any intention I have to

Date

leave Australia

•

I will not engage in employment that is not approved

by my employer as part of a rehabilitation program

while in receipt of compensation benefits under the

Seafarers Act

•

I will advise my employer if I receive weekly payments

or a lump sum from a Superannuation Fund or the

Seafarers Retirement Fund, or from any other source

with respect to this injury or illness

•

I am aware that where my injury has lasted, or is

likely to last, 28 days or more and has resulted in an

impairment or incapacity to work that I must:

(i) participate in an assessment of my capacity to

undertake a rehabilitation program, and

(ii) subject to that assessment, participate in an

agreed rehabilitation program.

•

the information I have supplied on this form and any

other attachment is true and accurate

•

I am aware that the making of a false or misleading

claim or false or misleading statement in support of

this claim is punishable by law under the Criminal

Code Act 1995 and, in that event, I may be liable for

prosecution

•

I am aware that any monies paid by the employer as a

result of a false or misleading statement or claim may

be recovered by the employer.

SEA01.1 May 2012

Australian Government Claim For Workers' Compensation Page 7

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