Australian Government Claim For Workers' Compensation Page 8
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8Checklist
Please use this Checklist as a guide to ensure that you
have completed this form and included all necessary
attachments before it is given to your employer.
Check that you have answered all the questions
you are required to answer and have signed the
Authorisation, declaration and acknowledgement.
Medical information
Have you attached an original medical certificate(s)
from a legally qualified medical practitioner?
Additional details
If your injury or illness happened while travelling to or
from your workplace, a training facility or other authorised
location and:
•
you travelled a route other than the direct route
(Question 18), have you attached a map of
the route taken?
•
the journey was interrupted (Question 19),
have you attached a separate sheet stating
the reason for, and the duration of, the
interruptions?
•
the police attended (Question 20), have you
attached a copy of the Police Statement or
provided the Police Event number or Police
Reference number?
If there were more than two witnesses to your injury
(Question 30), have you attached details of the
other witness(es)?
If you are claiming for loss/damage to property
(Question 38), have you attached receipts or
evidence of purchase or replacement of
repaired property?
If you intend to make a claim for compensation
against more than one employer in relation this
same injury or illness, have you provided a notice
to each employer stating the name and address of
the other employer(s)?
If you consider that another employer or employers
materially contributed to the injury or illness, have
you provided the employer against whom this claim
is being made with a notice stating the name and
address of the other employer or employers.
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SEA01.1 May 2012
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