Claim form
1894_ST 01/09
What is this form?
The information in this form can be
provided to:
This form can be used to notify a workplace injury or seek
compensation payments if you have been injured at work with
Employers Mutual
an employer registered in South Australia. Alternatively, this
By phone:
1300 365 105
information can be provided by telephone to Employers Mutual,
By fax:
(08) 8127 1200*
WorkCoverSA or the self-insured employer (see information to
By post:
GPO Box 2575, Adelaide SA 5001
the right).
Online at:
Receiving this information will enable a request for
OR
compensation to be considered and will provide sufficient
information for the case manager to assist in the return to work
WorkCoverSA
process.
By phone:
13 18 55 (Service Centre)
If there is insufficient space provided for any of the questions,
By fax:
(08) 8233 2466*
please attach additional information. A copy of this form should
By post:
GPO Box 2668, Adelaide SA 5001
be kept for your records.
OR
Self-insured employer
Who can fill out this form?
In accordance with the procedures issued by the individual
• An injured worker
employer.
• An employer*
*forms can be torn at perforation for faxing.
• A representative, such as a treating doctor, first aid officer or
a worker’s relative or friend
If you need help filling in this form or have
It is important to ensure that the employer (if you are not
any questions, speak to:
the employer) has also been provided with these details if
you are notifying WorkCover or Employers Mutual directly
• A supervisor
(unless the worker is not in employment at the time of
• The employer’s workers compensation or return to work
injury).
coordinator
* A n employer may complete this form to notify of an injury or begin the
• A union representative
claim process, however they may be asked to complete an Employer
Report Form if the claim will be ongoing after 13 weeks and additional
• A occupational health and safety officer/representative
information is required.
• Employers Mutual on 1300 365 105
• WorkCoverSA on 13 18 55.
Compensation Payments
If you are unable to fill in the form because it is in English, staff
Weekly compensation payments will be payable, within seven
from the WorkCover Service Centre will arrange interpreting
days (where possible) of the claims agent or self-insured
services. This interpreting service is available at no cost to you.
employer being notified of a workplace injury by telephone
or by receipt of this form.
For payments to commence, the mandatory information,
marked in bold and shaded on this form, must be received by
WorkCoverSA, Employers Mutual, or the self-insured employer.
A WorkCover Medical Certificate from the doctor must also be
provided. The employer and injured worker will receive a letter
within seven days advising whether compensation payments will
commence and what to do if they don’t agree with the decision.