Part one is for you to complete. Part two is for your supervisor and personnel area to complete. Once the questions in both parts have been answered, your employer must lodge the form with Comcare


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NamePart one is for you to complete. Part two is for your supervisor and personnel area to complete. Once the questions in both parts have been answered, your employer must lodge the form with Comcare
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COMCARE

Claim for Workers’ Compensation
This form is to be completed if you wish to claim workers’ compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act). Key features of the scheme are explained on the back of this form.

The form is in two parts. Part one is for you to complete. Part two is for your supervisor and personnel area to complete. Once the questions in both parts have been answered, your employer must lodge the form with Comcare.

The sooner you complete and submit this form, the sooner your claim can be processed.

Assistance to return to work—your responsibilities

• Find out about your agency’s rehabilitation policy.

• Ensure you let your supervisor and if relevant, the person in your agency who will be assisting you with your return to work (case manager) know if you are going to be away from work for an extended period (ie. greater than five days) due to a work related injury.

• You may need to undergo an assessment for rehabilitation.

• Talk to your case manager about your obligations and rights regarding rehabilitation and return to work.

• Actively participate in the return to work program.

• Talk to your case manager or rehabilitation provider whose services have been secured to assist your return to work if you have any concerns about any rehabilitation program (return to work plan) developed for you.

If a rehabilitation program is developed to assist your return to work you must undertake the program as set out in the written return to work plan.

If you need support or assistance to return to work, please speak with your supervisor or agency case manager. For more information about rehabilitation visit www.comcare.gov.au

Privacy statement

Your privacy is important to us. We will only collect, use or disclose your personal information in accordance with the Privacy Act 1988. If Comcare does not collect personal information from you for the purposes of assessing your claim or related functions, we may not be able to determine your claim.

Comcare is the Commonwealth agency authorised by the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) to collect personal information relevant to an injured worker’s claim for the purposes of managing the compensation claim and for the management of the injured worker’s rehabilitation and the discharge of other functions and use of other powers under the SRC Act. For those purposes, Comcare may need to collect from, use and disclose your personal information to the following parties:

• your employer at the date of your injury, your current employer and any subsequent employer

• your superannuation fund manager or trustee

• any health professional, hospitals, other health institutions, or service providers related to your claim

• your case manager

• your rehabilitation provider

• vocational and functional assessor

• employment agencies

• legal advisors and law enforcement authorities

• personnel engaged by Comcare to conduct research related activities

• the Safety, Rehabilitation and Compensation Commission

• Comcare fraud investigators

• inspectors appointed under section 156 of the Work Health and Safety Act 2011

• any relevant third party (or insurer) considered by Comcare to have contributed to the injury, illness or impairment

• any other person assisting Comcare in the performance of its functions or exercise of its powers

• any other entity where there is legal obligation to do so (for example, but not limited to, responding to the direction of a court to produce documentation)

We want to ensure personal information collected, used, stored or disclosed is accurate, up-to-date and complete. Comcare’s Privacy Policy contains information on how you can request access to personal information held about you and how to seek correction of that information.

You may make a complaint to us if you consider that Comcare has interfered with your privacy or otherwise breached its obligations under the Privacy Act 1988. Our Privacy Policy contains more information about how to make a complaint and how we will respond.

Comcare is not likely to disclose personal information to a person who is not in Australia or an external Territory, unless the information relates to an incident, investigation, injury or illness sustained while overseas, or treatment provided by an overseas practitioner. If disclosure of personal information is made to an overseas recipient, Comcare will comply with obligations regarding disclosure to overseas entities (Australian Privacy Principle 8).

For further information about our information handling practices, for a copy of our Privacy Policy, to request an amendment of your personal information or to make a privacy complaint, please refer to www.comcare.gov.au/privacy, contact us on 1300 366 979 or email privacy@comcare.gov.au
How to claim workers’ compensation

Fill in this form

Please complete using black or blue ink in answering the questions in Part 1 of this form.

Not all of the questions in Part 1 of this form will apply to you. If a question does not apply to you or your circumstances, write N/A in the space provided.

If your answers do not fit in the space provided, please attach additional pages with the details.

If your circumstances are reasonably simple and you have information readily at hand, you should be able to complete this form in less than 25 minutes.

Once you have filled in Part 1 of this form and attached all the documents you need to support your claim, you must sign the declaration on page 9.

If you were not employed by the Australian or ACT government at the time you were injured or contracted your illness, you may not have an entitlement to workers’ compensation under the SRC Act. If you are unsure, please call Comcare on 1300 366 979.

Collect all the documents you need

You will need to provide an original medical certificate stating that you have a work-related injury or illness.The certificate must state a precise medical diagnosis.

If you are claiming for chiropractic, physiotherapy or osteopathic treatment only and not for payment for any time you have taken off work, you will need only to provide an original certificate from your treating chiropractor, physiotherapist or osteopath.

In all other cases, you will need to provide an original medical certificate from a legally qualified medical practitioner (for example a general practitioner or medical specialist).

If you are claiming for an illness or disease, your medical practitioner will also need to provide information that indicates how your employment with the Australian or ACT governments contributed to your medical condition.

The form will also tell you which other documents or information you will need to provide to support your claim.

Use the checklist at the end of Part 1 of this form to make sure you have provided all the required information.

Lodge this form

Provide this form and attachments to your supervisor.

Your employer needs to complete Part 2 of this form.

If you are no longer employed, you must provide this form to the employer for whom you worked when you were injured or contracted your illness. In some cases, the employing department or organisation may no longer exist or may have changed its name. If this is the case, please call Comcare on 1300 366 979.

When Part 2 of this form has been completed, the form and attachments will be sent to Comcare. Comcare will write to you to let you know the claim has been received and will advise you in writing of any decisions made on your claim.

Do you need help with this form?

If you need assistance to complete this form, call Comcare on 1300 366 979 (for the cost of a local call). If you need translating or interpreting assistance, please call 13 14 50.
Claim for Workers’ Compensation
Part 1 – Applicant to complete
About You

1. What is your full name?

Title Mr ☐ Mrs ☐ Ms ☐ ☐ Other_______________________

Surname______________________________________________

Given name(s)_________________________________________

2. Do you have, or have you
ever had, any other name(s)?

For example: maiden name or previous married name.

No ☐

Yes ☐ è What name(s)?_________________________________

3. Sex:


______________________________________________________

4. When were you born?

_____________________________________________________

5. How can we contact you during the day?

Home telephone number_________________________________

Work telephone number__________________________________

Mobile phone number___________________________________

Preferred email_________________________________________

6. Do you have a preferred language other than English?

No ☐ Yes ☐ è What language?___________________________

Do you need an interpreter?

No ☐ Yes ☐ è Call the Translating and Interpreting Service on
13 14 50

7. Where do you live?

Your permanent home address
(please give street address and not a PO Box)

_____________________________________________________

__________________State_______________Postcode_________

8. Do you have a different postal address?

No ☐ Yes ☐ è Please give details

_____________________________________________________

_____________________________________________________


9. Do you need another person to act on your behalf for this claim?

For example—a partner, support person or solicitor.

No ☐ Yes ☐ è Please give details

Their name____________________________________________

Their daytime telephone number___________________________

Postal address__________________________________________

_____________________________________________________



About your injury or illness

10. For what injury or illness are you claiming workers’ compensation?

Quote the precise diagnosis as stated on a medical certificate.

For example: diagnosed conditions are: disc prolapse, strained cruciate ligament and anxiety disorder, and they are not: back pain, sore knee and stress.

Diagnosed conditions

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

Please attach ORIGINAL certificates detailing your work-related injury or illness.

11. What part(s) of your body has been most affected by your injury or illness?
For example: right knee, upper left arm, lower back, neck, respiratory system, mental state.

Part(s) of body injured

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________


12. When were you injured or when did you first notice you were ill?

Give approximate time if exact time is not known.

Date________________________________________________

Time_________________________________________am/pm

13. When and where did you first seek medical treatment for your injury
or illness?

Date________________________________________________

____________________________________________________

Telephone number____________________________________

14. Have you been referred to a specialist or for any diagnostic tests for your injury or illness?
For example: X rays, pathology, ECG or evaluation by a psychiatrist or psychologist.

No ☐ Yes ☐ è Who were you referred to and why?

Name of specialist______________________________________

Address of specialist____________________________________

______________________State____________Postcode_______

Telephone number_____________________________________

Nature of referral (For example: X rays)

_____________________________________________________

If you were referred to more than one specialist, please attach details.

15. Have you undertaken any of the following treatments for your claimed condition?


Tick any relevant boxes

Physiotherapy ☐ Chiropractor ☐ Hospital treatment ☐

Pharmaceuticals ☐ Counselling ☐

Other (please specify)___________________________________



16. Have you ever had a similar symptom, injury or illness, work-related
or otherwise?

No ☐ è Go to Question 19

Yes ☐ è Describe the symptom, injury or illness and the parts of the body affected. Give approximate dates.

____________________________________________________

___________________________________________________

17. Have you ever received medical treatment for a similar injury or illness?

No ☐ Yes ☐ è Please give details

Date____________________________

Name of doctor_________________________________________

Telephone number_______________________________________

18. Have you ever claimed workers’ compensation for a similar injury or illness?
Please answer this question even if the claim was not accepted.

No ☐ Yes ☐ è Please give details

Year claimed____________________________

Name of insurer________________________________________

Name of employer at the time____________________________

Claim reference number (if known)_________________________

19. How long do you expect to be absent from your workplace due to your injury or illness?

No absence ☐ Less than 1 week ☐ Less than 12 weeks ☐

Longer than 3 months ☐
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