EMPLOYERINJURY CLAIM REPORT

WORKSAFE VICTORIA

This report can be used to lodge a Workers’ Compensation Claim in New South Wales, Queensland, or Victoria.FOR589/10/12.16

TheAgentwillwritetoyouandadviseyouiftheclaimhasbeenaccepted.Adecisiontoacceptorrejecttheworker’sclaimwillusuallybemadewithin28daysfromthetimetheclaimisreceivedbytheAgent.Tofindoutmoreabouttheprocessofmakingaclaim,andwhatassistanceisavailabletosupportthereturntoworkprocess,talktoyourAgent,refertothebrochureWhat to do if a Worker is Injured, a Guide for Employers,orvisitthewebsiteatworksafe.vic.gov.au.

• Tonotifyyouthatthey’vebeeninjuredatworkassoonaspossible,andcompletetheinjuryregisterattheworkplace.• Toreporttheaccidenttothepoliceiftheinjurywastheresultofamotorvehicleaccident.Otherwisetheirclaimmaynotbevalid.• ToseetheirmedicalpractitionertoobtainaWorkSafe Certificate of Capacity (medical certificate)iftheywanttoclaimweekly

compensationpayments,andtogiveyouacopyalongwiththeirclaimform.• TogiveyouthecompletedWorkers’ Injury Claim FormandanyWorkSafe Certificates of Capacity (medical certificates)assoonas

possibleafterbeinginjured.IfyourworkerhasdifficultygivingyoutheirclaimformoranyWorkSafe Certificates of Capacitytoyou,oryourefusetotakereceiptofthesedocuments,theworkerhastherighttolodgetheclaimdirectlywiththeAgent.TheworkercanalsonotifytheAgentorWorkSafedirectlybysendingthemthe“EarlyNotification”copyoftheWorker’s Injury Claim Form.

• Toworkwithyoutodevelopareturntoworkplan(ifrequired).

✓ Signtheemployer’sdeclarationattheendofthisform.Theformcannotbeacceptedwithoutyoursignature✓ Keepacopyofalldocumentsforyourrecords✓ Confirmwithyourworkerinwritingthatyou’vebeennotifiedofthisclaim(youcandothisbygivingthemacopyoftheWorker’s

Injury Claim Formwhensigned)✓ Iftheclaimincludesweeklypayments,sendthiscompletedform,thecompletedWorker’s Injury Claim Form,andanyWorkSafe

Certificate of Capacity (medical certificates)toyourAgentassoonaspossible,butnolaterthan10daysafterreceivingthemfromyourworker-oryoumaybefinanciallypenalised

✓ Iftheworkerhasanentitlementtocompensationandtheclaimisaccepted,paytheworkerweeklypayments,✓ Paytheworker’sinitialmedicalandtreatmentexpenses,uptothelevelspecifiedbyyourWorkSafepolicy.Ifthisthresholdis

exceeded,forwardthisreport,theclaimform,copiesofaccountspaid,andanyunpaidaccountstoyourAgentwithin10days

• YourWorkSafeVictoria(WorkSafe)Agent• TheWorkSafeAdvisoryService:freecall1800136089or(03)96411444

FOR HELP COMPLETING THIS FORM OR FOR MORE INFORMATION CONTACT:

AS THE EMPLOYER YOU NEED TO:

Formoreinformationonyouremployerreturntoworkobligations,andhowyoucanassistyourworkertoreturntowork,refertothebackofthisformorvisitthewebsiteatworksafe.vic.gov.auandclickoninjuries and claims,thenreturning to work.

• Talk with your worker to plan for their return to work as soon as you receive their claim form or WorkSafe Certificate of Capacity (medical certificate)

• Talk to your worker’s medical practitioner or healthcare provider about your worker’s limitations, what parts of their work they could do and any suitable duties that you may have available. This can help inform the medical practitioner or healthcare provider when they review and evaluate your worker’s capacity for work.

• Talk to your Agent about what support is available to help your worker return to work and overcome their injury as quickly as possible.

• When your worker has some capacity for work, provide them suitable employment. When they no longer have an incapacity for work, provide them with their pre-injury employment.

• Appoint a return to work coordinator who is competent to help you meet your return to work obligations and support the worker’s return to work

GETTING YOUR WORKER BACK TO WORK

✓ MakesureyouprovideyourAgentwithfulldetailsofyourworker’searnings,thiscanincludeapayslip,payrollreportorotherdocumentwithearningsdetails.AformisavailableontheWorkSafewebsitewhichwillhelpyouaccuratelydeclareallofyourworker’searnings.Pleaserefertothebackpageofthisformformoreinformationaboutaworker’searnings.

YOUR WORKER’S RESPONSIBILITIES:

✓ Answerallofthequestionsonthisform.Carefully complete this form USING A DARK BLUE or BLACK PEN.Theformmaybereturnedtoyouifitisincomplete

Familyname

Givennames

Streetaddress

Suburb Postcode

Daytimecontactphonenumber/s

Dateofbirth Gender

Male Female

Streetaddressoftheworker’susualworkplace

Suburb

State Postcode

IftheincidentdidNOThappenatoneofyourworkplaces,pleasegivethenameoftheemployerresponsiblefortheworkplaceEmployer’sname

Whatistheworker’susualoccupation?

Whatarethemaintasksperformedbytheworkerintheirusualoccupation?

Whichofthefollowingapplytotheworker?(Please tick all relevant boxes) Casual Student

Full-Time Part-Time Apprentice Volunteer

Contract Trainee Agency worker Contractor

Permanent Temporary Seasonal Jockey

Other?Whendidthisworkerstartworkingforyou?

Legalname

Tradingname

Employer’sschemeregistrationnumbereg. WorkSafe Employer, Policy, or Employer Registration Number

Employer’sreferencenumber(Your reference)

Streetaddress

Suburb

State Postcode

Postaladdress

AustralianBusinessNumber

ACN/ARBN

Division CostCentre

Whatisthemainbusinessactivityattheincidentsite?

Name,position,anddaytimecontactnumberofemployercontact

Nameanddaytimecontactnumberofthereturntoworkcoordinator(ifany)

AddressforcorrespondencerelatingtothisclaimPostaladdress

State Postcode

Employercontacte-mailaddress

Ifyouneedaninterpreter,whatlanguagedoyouspeak?

Whendidyoureceivetheworker’scompletedclaimform?

Whendidyoureceivetheworker’sfirstmedicalcertificate?

1 EMPLOYER’S DETAILS

3 WORKER’S EMPLOYMENT DETAILS

M W H

* This question is required for NSW claims

*Policyperiodofinsuranceto

This question is required for NSW claims

Howmanyworkersareemployedatthisworkplace?

This question is required for Victorian claims

Workplacenumberforworker’susualworkplace

* These questions are required for NSW and QLD claims

Istheworkeremployedunderanyofthefollowing?

Federal award Registered industrial agreement

State award No agreement or award

WCA Jobcover Program Registered enterprise agreement

*Whatisthetitleoftheawardoragreement?

4 WORKER’S RETURN TO WORK DETAILSIftheworkerhasreturnedtowork,pleaseprovidethedate

What duties are they doing? Full Suitable/Modified

2 WORKER’S DETAILS

This report can be used to lodge a Workers’ Compensation Claim in New South Wales, Queensland, or Victoria

Whatistheworker’sminimumweeklywage?As specified by the award or agreement

EMPLOYERINJURYCLAIMREPORTPleaseindicateinwhichStateyouwanttolodgethisclaim: New South Wales Queensland Victoria

FOR589/10/12.16 PLEASE COMPLETE FORM USING A DARK BLUE or BLACK PEN

I have read the information provided in this form. I declare that the information I have supplied in this form, and any attachment to this form, is true and correct and that no information has been suppressed or omitted from this report to the best of my knowledge. I understand that the making of a false or misleading statement concerning a claim is punishable by law and that I may be prosecuted.

Signatureofemployer’srepresentative Date

Name

Position

Whichofthefollowingincidentcircumstancesapply?

While working at the usual workplace

While working away from the usual workplace

During a meal-break or authorised recess at work

While away from work during a recess

Travelling to or from work*

A motor vehicle accident while working*

Iftheinjurywastheresultofdrivingorusingamotorvehicleortheuseofpublictransport,pleaseprovidetheregistrationnumber/sofanyvehiclesinvolved State

Hastheworkerhadasimilarinjury/conditionorpersonalinjuryclaimbeforethatrelatestothisinjury/condition?Please give details, including claim numbers

Whendidtheworkerreporttheinjurytoyou?

Whowastheinjuryreportedto?

Whatarethenamesanddaytimecontactdetailsofanywitnesses?

Doyoubelievethattheinjury/conditionwascausedorcontributedtobytheworker,orathirdpartysuchasamanufacturerorsupplier?Please give details if relevant

Doyouwanttoprovideanyadditionalinformationthatmayassistinthedeterminationofliabilityorthemanagementofthisclaim?eg. Do you dispute liability, and, if so, why?

7 INCIDENT DETAILS 8 ADDITIONAL INFORMATION

9 EMPLOYER’S DECLARATION

How many hours do they work each week?

Howmanydayshavebeenlost?Haveyouprovidedtheworkerwithareturntoworkplan,takingintoaccounttheinjury/condition?Please attach a copy of the return to work plan or agreement, or please explain why you have not provided a plan.

Iftheworkerhasnotreturnedtowork,doyouknowofanyissuesthatwoulddelayorpreventareturntowork?

5 CLAIM CONFIRMATION DETAILSDoyouagreethatthedetailsprovidedinsections2&4oftheWorker’s Injury Claim Formarecorrect? Yes NoDoyouacceptthatyourworkerhasaninjury/conditionwhichiswork-relatedandoccurredwhileinyouremployment? Yes NoNote: If you agree the injury is work-related, and believe that the details provided in sections 2 & 4 of the Worker’s Injury Claim Form are correct, you do not need to complete the remainder of this form except for section 9, which MUST be completed. Otherwise, please complete any relevant questions in sections 6, 7 and 8 of this Report.

6 WORKER’S EARNING DETAILSPlease complete this section if you wish to claim for weekly paymentsHowmanystandardhoursdidtheworkerworkeachweekbeforebeinginjured?Exclude overtime

Whatweretheworker’susualworkinghours?For example, Monday to Friday, 8.30 am to 5.30 pm

Whatwastheworker’susualgrosshourlyrate?Exclude overtime & shift allowances

Whatwastheworker’susualgrossweeklyearnings?Exclude overtime & shift allowances

Pleaseprovidedetailsofanyovertimeorshiftwork

Average weekly overtime

Weekly shift allowancePlease provide payroll records covering the 12 months prior to injury

hrs

hrs

This report can be used to lodge a Workers’ Compensation Claim in New South Wales, Queensland, or Victoria

Whatistheworker’sinjury/condition,andwhichpartsofthebodyareaffected?

Whathappenedandhowwastheworkerinjured?

Whatisthestreetaddresswheretheincidentoccurred?

Suburb

State

Whatdateandtimedidtheinjuryoccur? AM PMWhatdateandtimedidtheworkerfirstceasework? AM PM

hrs

days hrs

* For NSW incidents a journey claim form must also be completed

days hrs

INFORMATION FOR EMPLOYERS AND RETURN TO WORK COORDINATORS (RTWC)GETTING YOUR INJURED WORKER BACK TO WORK:• Youmustcommenceplanningyourworker’sreturntoworkassoonasyoureceivetheirclaimforweeklypaymentsor

WorkSafe Certificate of Capacity (medical certificate),eveniftheydonothaveacurrentcapacityforwork.

• Planninginvolvesobtainingrelevantinformationaboutyourworker’scapacityforworkandconsideringreasonableworkplacesupport,aidsormodifications.Italsoinvolvesassessingandproposingsuitableemploymentoptions,andconsultingwithyourworker,theirmedicalpractitionerorhealthcareproviderandoccupationalrehabilitationprovider(ifoneisinvolved).

• Ifyouneedassistancewithreturntoworkplanningorassessingsuitableemploymentoptions,contactyourAgentimmediately.YourAgentmayapprovetheuseofanOccupationalRehabilitationprovidertohelpyou.

• Sendtheproposedsuitableorpre-injuryemploymentoptionstotheworker’smedicalpractitionerorhealthcareprovider.Thiswillhelpthemunderstandtheavailabilityofsuitableemployment,andinformthemwhenmakinganassessmentoftheworker’scapacityforwork.

• WorkSafe’s Return to Work Proposaltemplatemayassistyoutocommunicatethesesuitableorpre-injuryemploymentoptionstothemedicalpractitionerorhealthcareprovider.

• Ideallyareturntoworkproposalwouldbesignedbyallpartiestoindicatetheirsupport,howeveritisnotmandatory.

• Youmustprovideyourworkerwithclear,accurateandcurrentdetailsoftheirreturntoworkarrangements,andregularlyreviewandupdatetheseasyourworker’sconditionwillchangeovertime.

• Whenyourworkerhassomecapacityforwork,youhavealegalobligationtoprovidethemwithsuitableemployment.Whentheynolongerhaveanincapacityforwork,yourlegalobligationistoprovidethemwiththeirpre-injuryemployment.Employerswhodonotmeettheseobligationsriskpenalties,includingfinesandprosecutionsinthecourts.

FURTHER INFORMATION AVAILABLE TO SUPPORT YOUR RETURN TO WORK PLANNINGYoucanobtaininformation,forms,publicationsandfactsheetstohelpyouplanaworker’sreturntoworkfromourwebsite,worksafe.vic.gov.au.Clickon‘Injury and Claims’then‘Returning to work’.

Thisinformationincludes:

• What to do if a worker is injured - a guide for employers

• usefultoolsandtemplatestohelpyouassessandproposesuitableemployment,andclearlysetoutaworker’sreturntoworkarrangements.

YoucanalsocontactyourAgentforfurtheradviceandguidanceaboutreturntoworkplanningandpreparation.

ADDITIONAL SUPPORT FOR RETURN TO WORK COORDINATORSMaterial,guidanceandtrainingareavailabletohelpreturntoworkcoordinatorsfulfiltheirroleandassisttheiremployermeettheirreturntoworkobligations.Forfurtherinformation,visittheWorkSafewebsiteworksafe.vic.gov.au

ReturntoWorkCoordinatorscanalsosignuptotheWorkSafeReturn to Work Coordinator Register.ThisenablesReturntoWorkCoordinatorstoreceivekeyinformationon:

• ReturntoWorkCoordinatortraining

• ReturntoWorkEmployernetworks

• newreturntoworkforms,publicationsandinformation

• legislativechangesimpactingreturntoworkprocessesandrequirements

Registrationisvoluntarybutisstronglyencouraged.Registerathttp://rtw.worksafe.vic.gov.au

CALCULATING ENTITLEMENT TO WEEKLY PAYMENTSWeeklypaymentsarecalculatedbasedontheworker’spre-injuryaverageweeklyearnings(PIAWE)forthe52weeksbeforetheirinjury.Iftheyhavebeenemployedbyyouforlessthan52weeks,theiraverageweeklyearningsfortheperiodofemploymentareused.

What you need to provide about your worker’s earnings

SothattheAgentcancalculatetheworker’sPIAWE,youwillneedtoprovidedetailsofanyofthefollowingpaymentsthatyouhavemadetotheworkerinthe52weeksbeforetheinjury(oriftheperiodofemploymentwaslessthan52weeks,intheperiodofactualemployment).

• Worker’sbaserateofpay

• Overtimeandshiftallowancespaid

• Piecerates,tallybonusesandcommissionspaid

• Non-pecuniarybenefitsincludingresidentialaccommodation,useofamotorvehicle,paymentofhealthinsuranceorpaymentofeducationfees

• Anysalarysacrificearrangements

YouwillalsoneedtotelltheAgentofanypromotionorvoluntarydemotionoftheworkerinthe52weekperiodbeforetheinjury.Ifyourworker’searningsincludeanyoftheitemslistedabove,andarenotcapturedinpart6ofthisformyoucancompletetheCalculating Pre-Injury Average Weekly EarningsformthatisavailableontheWorkSafewebsite,worksafe.vic.gov.au toensureyouhaveprovidedalltheworker’searningsdetails.