Fillable Workcoversa Claim Form printable pdf download

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

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.

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.

Workcoversa Claim Form

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