Worker's Injury Claim Form


  • Worker's Injury Claim Form (PDF 306kb)
    Document Type: Form
    Keycode: FOR502/07/08.07
    Category: Injury and Claims 
    Publication Date: 12 September 2007
    Date First Published: 11 October 2006
    Summary: This form is to be completed if you suffer a work-related injury or condition.

About this form


If you suffer a work-related injury or condition, you (or someone else if you are unable to) must report it to your employer, in writing, within 30 days of becoming aware of it. Worker's Injury Claim forms must be completed in duplicate.

You can obtain a copy of the form from:

  • Your local Post Office;
  • Your Authorised WorkCover Agent;
  • The Advisory Service, or;
  • By printing the PDF copy available on this website and making a photocopy for your own records.

How to complete the form


Complete all pages of the form using a ball point pen and print clearly, and remember to sign the declaration on the form. Your WorkCover agent may require additional information to help determine your entitlement.


Where to send the form


Give the completed and signed claim form to your employer. After your employer has also signed and dated the form, keep a copy for your own records. Your employer must forward your claim to your VWA WorkCover agent. After you have given a claim for weekly compensation to your employer, you can notify your VWA WorkCover agent of the claim by sending the Early Notification copy of the claim form and a copy of your medical certificate to your VWA WorkCover agent.

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